Methods and Devices for Endoscopic Access to the Heart

ABSTRACT

Disclosed are devices for cardioscopic and pericardioscopic access to the heart, including direct access to the left atrium. In certain embodiments, the device may comprise an atrial portal having a configuration such that the distal end of the atrial portal can access the atrium while the proximal end of the portal can extend to outside of the subject. The devices and methods may also include a pericardioscopic portal for emplacement of the atrial portal. Also, methods for using such atrial portals and pericardial portals to perform surgery on the heart, and in some cases to directly access the left atrium, and systems (e.g., kits) comprising these portals in combination with other therapeutic devices are disclosed.

RELATED APPLICATIONS

This application claims priority to U.S. Provisional Patent ApplicationNo. 61/203,173, filed Dec. 19, 2008, and U.S. Provisional PatentApplication No. 61/262,372, filed Nov. 18, 2009. The content of U.S.Provisional Patent Application Nos. 61/203,173 and 61/262,372 areincorporated by reference in their entireties herein.

FIELD OF THE INVENTION

The present invention relates to methods and devices for endoscopicaccess to the heart, including direct endoscopic access to the leftatrium.

BACKGROUND

Traditionally, access to the left atrium and the structures within theleft atrium has been limited to direct surgical access via sternotomy orthoracotomy or by percutaneous access via the femoral vessels andcrossing the intra-atrial septum from the right to the left atrium.Although some therapies may be applied to the left atrial surface (asfor atrial fibrillation), there are other therapies which are beneficialwhen applied within, or through, the left atrium, rather than on theleft atrial surface. These therapies may include, but are not limitedto, the treatment of mitral valve pathology, aortic valve pathology,atrial and ventricular dysarrhythmias, management of the left atrialappendage, and placement of leads and sensors to manage heart failure inconjunction with implanted devices.

To gain access to the left atrium via surgical approach (sternotomy orthoracotomy) cardiopulmonary bypass is usually required. Once this isinitiated, the left atrium can be surgically opened with an incision.These incisions have allowed the introduction of large instruments andthe surgeon's hands into the chest and abdomen to perform complexsurgical procedures. The surgeon can then perform the necessaryprocedure to the left atrium and to structures inside the left atrium.

Interventional cardiologists or electrophysiologists may gain access tothe left atrium by percutaneous cannulation of the femoral vein, andpositioning a catheter across the atrial septum into the left atrium.Via this trans-septal approach, cardiologists can perform percutaneousprocedures within the left atrium, such as catheter ablations. However,the trans-septal approach is difficult to perform and leaves the patientwith a potential atrial septial defect.

Also, patients with a failing heart may require mechanical cardiacsupport either temporarily or permanently, to remain alive. Mechanicalsupport can be temporary until the heart recovers and can return toindependent function, or may be long-term until an appropriate heartbecomes available for transplantation. This type of mechanical supportcan require the placement of large cannulas in the heart and greatvessels (aorta, pulmonary artery) to pump the blood for the heart. Whenthe right heart fails, a device can be connected to the right atrium andpulmonary to pump blood from the body to the lungs. When the left heartfails, a device may be connected to the left atrium and the aorta topump blood from the lungs to the body. In some situations, a patient mayrequire both a right and a left heart assist device. In both situations,these mechanical support devices are placed during open heart surgicalprocedures using a median sternotomy and cardiopulmonary bypass.

There are currently no cardioscopic devices or methods to directlyaccess the left atrium and certain other regions of the heart. Thus,there is a need for devices and methods to simplify access to the heart.In this way, risk to the patient, and trauma resulting from the surgerycan be minimized. For example, there is a need for the cardioscopic andpericardioscopic devices, methods and systems of the present inventionwhich encompass methods, devices, and systems for cardiac assistance(temporary or long-term), epicardial lead placement, ablative therapy,and placement of epicardial shock devices, and other therapeutictreatments that can be accomplished while the heart is beating.

SUMMARY

The present inventions relate generally to devices and methods fordirectly visualizing and operating upon and within the heart, includingthe left atrium and the right atrium.

In certain embodiments, the present invention comprises the developmentof new, and the improvement of existing, surgical tools,instrumentation, techniques, and methods to directly visualize andperform procedures upon and within the heart, including the left atrium,the right atrium, and structures within, and in proximity to, the leftatrium and the right atrium. Utilizing cardioscopic access to theatrium, instrumentation may be positioned within the atrium directly.

The present invention, in certain embodiments, encompasses methods,devices and systems to access and perform procedures within the heart,including the left atrium, the right atrium, left ventricle, rightventrical, left atrial appendage, aorta, and to the aortic and mitralvalve via the left or right atrium. Embodiments of the present inventionalso encompass methods, devices and systems to access and performprocedures within the pericardium to allow direct cannulation of theleft atrium, left ventricle, right atrium, right ventricle, aorta, andpulmonary artery for cardiac support technology.

Embodiments of the present invention also encompass methods, devices andsystems to access and perform electrophysiologic procedures includingendocardial ablation within the heart, including the left atrium and theright atrium, on the right and left ventricles, andepicardial/endocardial lead placement. Such methods, devices and systemsmay employ an atrial portal and/or pericardial portal as describedherein. Also, such methods, devices and systems may employ a pericardialportal as described herein. The methods, devices and systems of thepresent invention may comprise accessory devices such as needles, wires,and ports designed to be used with embodiments of either the atrialportal or the pericardial portal.

The present invention may be embodied in a variety of ways. For example,in one embodiment, the present invention comprises a method to accessthe atrium of a heart of a subject, the method comprising; inserting thedistal end of an atrial portal into the pericardium of the subject;manipulating the proximal end of the atrial portal to position thedistal end of the atrial portal at the surface of the atrium;determining an entry location for the atrial portal to be inserted intothe atrium; inserting the atrial portal into the atrium; and securingthe position of the atrial portal in the atrium.

In other embodiments, the present invention comprises devices foraccessing the atrium in a heart in a subject, the device comprising anatrial portal having a configuration such that the distal end of theatrial portal can access the atrium endoscopically via the pericardialsac while the proximal end of the atrial portal can extend to outside ofthe subject.

In yet other embodiments, the present invention comprises systems foraccessing the atrium of a heart in a subject, the system comprising anatrial portal having a configuration such that the distal end of theatrial portal can access the atrium endoscopically via the pericardialsac while the proximal end of the atrial portal can extend to outside ofthe subject.

In an embodiment, the atrium accessed by the devices, methods andsystems of the invention is the left atrium.

DESCRIPTION OF THE FIGURES

The present invention may be further understood by referring to thefollowing non-limiting figures which illustrate embodiments of thepresent invention.

FIG. 1 illustrates the surface anatomy of a person and a location forinsertion of a pericardial and atrial portal in accordance with anembodiment of the present invention.

FIG. 2 illustrates a pericardial portal within the peritoneal cavity inaccordance with an embodiment of the present invention.

FIG. 3 illustrates the view at the distal end of a pericardial portal inaccordance with an embodiment of the present invention.

FIG. 4 illustrates a similar view of the pericardial anatomy as seen inFIG. 3, showing an entry location for placement of a left atrial portalin the left atrial wall in accordance with an embodiment of the presentinvention.

FIG. 5 illustrates a purse string suture that has been placed around anentry location for a left atrial portal in accordance with an embodimentof the present invention.

FIG. 6 illustrates a left atrial portal passing into the left atrialwall and secured by a purse string suture in accordance with anembodiment of the present invention.

FIG. 7, panels A-D, shows a suture capture device, where panel A showsthe device which is passed through a tourniquet, panel B shows captureof the suture, panel C shows the suture being retrieved from the distalend of the tourniquet, and panel D shows the suture from a purse stringsuture in the atrial wall pulled through the tourniquet and out theproximal opening, so that tension applied to the proximal end of thesuture can be used to tighten the distal ends of the suture inaccordance with an embodiment of the present invention.

FIG. 8, panels A-D, illustrates a pericardial portal with a tourniquet,a left atrial portal, and an endoscope inside the distal opening of thepericardial portal in accordance with an embodiment of the presentinvention, where panel A shows an atrial portal in the lumen of apericardial portal, panel B shows a guide wire being inserted into theentry location for an atrial portal under view of an endoscope in apericardial portal, panel C shows an atrial portal being inserted in theatrium over a guide wire, and panel D shows an atrial portal in positionin the atrium wall, with the purse string sutures tightened around theatrial portal using a tourniquet inside a pericardial portal.

FIG. 9, panels A-H, demonstrates placement of a left atrial portal in aleft atrial wall in accordance with an embodiment of the presentinvention, where panels A-D show the components separately, and panelsE-H shows an embodiment that employs the left atrial portal, dilatorintroducer, and introducer needle substantially simultaneously, suchthat panel A shows purse string sutures positioned with pledgets on theepicardial surface, and a hollow bore needle is placed into the leftatrium; panel B shows a guide wire passed through the needle and intothe left atrium; panel C shows the needle removed and the guide wirepassing from outside the abdomen, through a pericardial port (not shown)and inside the left atrium; and panel D demonstrates the position of aleft atrial portal within the left atrium over the guide wire where aremovable dilating introducer enlarges the opening of the left atrialwall over the wire; panel E shows a purse string suture and pledgets onthe left atrial epicardial surface, and the left atrial portal, dilator,and needle placed in the middle of the purse string suture; panel Fshows the needle advanced into the left atrium; panel G shows a guidewire been passed through the needle and positioned inside the leftatrium allowing the left atrial portal, dilator, and needle to beadvanced as one unit through the left atrial wall; and panel H shows theleft atrial portal within the left atrium over the guide wire with theneedle removed from the atrium and back into the atrial portal.

FIG. 10, panels A-H, illustrates other embodiments of a portal inaccordance with alternate embodiments of the present invention, wherepanels A and B show alternate embodiments of the distal end of an atrialportal; panels C and D shows an embodiment of the proximal end of anatrial portal; panel E depicts the an atrial portal with a nonremovableport, a one-way valve and a stopcock assembly; panel F shows anembodiment of a distal port in a head on view; panel G shows a side viewand panel H shows an end view of a triangular shaped proximal port withthree one-way valves.

FIG. 11 illustrates the inside of the left atrium with the left atrialportal shown with the internal portion of the distal cap seen within theinternal wall of the left atrium in accordance with an embodiment of thepresent invention.

FIG. 12 illustrates the distal end of a left atrial portal having adistal cap positioned in the left atrial wall and having a catheterpassing into the left atrium from outside the abdomen and through thecentral lumen of the left atrial portal in accordance with an embodimentof the present invention.

FIG. 13 illustrates a left atrial portal being positioned for repair ofa valve in accordance with an embodiment of the present invention.

FIG. 14 illustrates a valve and balloon dilator catheter and associateddilating balloon being positioned and expanded at the location of theaortic valve using a guide wire as a platform for manipulation intoposition in accordance with an embodiment of the present invention.

FIG. 15 illustrates an aortic valve stent prosthesis on a sheath with atapered distal end in accordance with an embodiment of the presentinvention.

FIG. 16 illustrates an aortic valve stent prosthesis emplaced in theaortic valve after delivery with a left atrial portal in accordance withan embodiment of the present invention.

FIG. 17 illustrates a mitral valve stent prosthesis emplaced in themitral valve in accordance with an embodiment of the present invention.

FIG. 18, panels A-C, illustrate a barbed needle as unsheathed (panel A),or being delivered using an introducer needle (panel B) and emergingfrom the introducer needle (panel C) in accordance with an embodiment ofthe present invention.

FIG. 19, panels A and B, illustrates how a barbed needle is advanced outof the end of an introducer needle, where a sheath over the suture isused to advance the suture and the barbed needle out of the distal endof the introducer needle, in accordance with an embodiment of thepresent invention.

FIG. 20 illustrates an introducer needle being used to deliver a barbedneedle to the posterior mitral valve annulus in accordance with anembodiment of the present invention.

FIG. 21 illustrates the positioning of a barbed needle in the posteriorannulus tissue of the mitral valve in accordance with an embodiment ofthe present invention.

FIG. 22 illustrates two barbed needles positioned in the posteriorannular tissue of the mitral valve in accordance with an embodiment ofthe present invention.

FIG. 23 illustrates the reduction of the annulus as the barbed needlespositioned in the posterior annular tissue of the mitral valve are drawncloser to each other in accordance with an embodiment of the presentinvention.

FIG. 24 illustrates posterior mitral valve reduction using ablation inaccordance with an embodiment of the present invention.

FIG. 25 illustrates emplacement of an intracardiac assist device for abridge to transplantation in accordance with an embodiment of thepresent invention.

FIG. 26, panels A-C, illustrates a pacing lead for use with an atrialportal in accordance with an embodiment of the present invention, wherepanel A depicts a pacing lead with the proximal end having the bipolaror unipolar lead attachment; panel B shows a head-on view of the distalend of the lead, and panel C shows the fixation unit for the lead.

FIG. 27, panels A-C, illustrates an atrial pressure sensor anddeployment of such a sensor in the left atrium in accordance with anembodiment of the present invention, where panel A shows the atrialpressure sensor, panel B shows deployment of the pressure sensor in theleft atrium, and panel C shows the atrial pressure sensor in a finaldeployed position.

FIG. 28 depicts a pericardial portal in accordance with an embodiment ofthe present invention in various views: right view (panel A), left view(panel B), and end view (panel C).

FIG. 29 shows a pericardial portal with ablation catheters on theepicardial surface of the left atrium and left ventricle in accordancewith an embodiment of the present invention.

DETAILED DESCRIPTION

Embodiments of the present invention include new devices, andimprovements to existing devices, instrumentation, and procedures forproviding direct access to the left atrium, or other regions of theheart, via minimally invasive, endoscopic approaches. In certainembodiment, the devices, methods and systems of the present inventioncomprise an atrial portal as described herein. In yet other embodiments,the devices, methods and systems of the present invention comprise apericardial portal as described herein. Embodiments of the presentinvention also comprise methods for using such atrial portals andpericardial portals to perform surgery on the heart, and systems (e.g.,kits) comprising these portals in combination with other therapeuticdevices.

Thus, in certain embodiments, the devices, methods and systems of thepresent invention may be used with accessory devices. Examples of suchdevices include, but are not limited to, devices and instrumentationsuch as needles, wires, and ports designed to be used for positioningthe atrial portal utilizing pericardioscopy or similar endoscopic orminimally invasive cardiac access. Non-limiting embodiments of suchdevices are depicted in the diagrams and description included herein.

In other embodiments, the devices, methods and systems of the presentinvention may comprise the use of existing catheters, needle passers,forceps, or other intracardiac devices.

As described herein, the use of pericardioscopy or cardioscopy can incertain embodiments of the present invention, provide direct access tothe pericardium and the left atrial surface. Without thepericardioscopic (e.g., pericardial portal) and cardioscopic (e.g.,atrial portal) devices, methods and systems of the present invention,direct visualization and manipulation of the left atrium is onlypossible via large and sometimes painful incisions. Utilizing apericardioscopic and cardioscopic approach, the left atrium can bedirectly cannulated using only minimally invasive, port accesstechniques and endoscopic instrumentation and visualization. Forexample, by directly cannulating the left atrium, catheters and devicescan be positioned into the left atrium with minimal difficulty.Procedures such as endocardial atrial or ventricular ablations, mitralvalve repair or replacement, aortic valve replacement, stent placement,management of intracardiac congenital defects or tumors, and managementof the atrial appendage, and endocardial lead and/or sensor placementare examples of procedures that may be performed using the devices,methods and systems of the present invention.

As used herein, a subject or an individual is an animal. For example,the subject may comprise a mammal. In one embodiment, the subject may bea human. In certain embodiments, the subject is a patient seekingmedical treatment (e.g., for a heart condition). The user of thedevices, methods, and systems of the present invention may be aphysician, veterinarian, or other type of health care professional.

As used herein, a portal is a chamber that provides access from outsideof the subject to an organ inside of the subject, such that proceduresmay be performed in the organ vial the portal. An endoscopic portal is aportal that has an endoscope or other imaging device at least partlycontained within its lumen such that the distal end of the portal, andtissues and/or organs positioned at the distal end of the portal, can beviewed by an operator at the proximal end. The portal thereby provides aconduit that can be fixed (if needed) at the organ to be treated, with adistal end that can be used to insert tools or devices in the organ.

As used herein, a cannula is a small tube or cylinder that is insertedinto the body and that may be used to insert fluid and or tools insidethe body. An endoscopic cannula is a cannula that has an endoscope orother imaging device at least partly contained within its lumen suchthat the distal end of the cannula, and tissues and/or organs positionedat the distal end of the cannula, can be viewed by an operator at theproximal end.

An endoscope is a small flexible tube with a light and lens that may beused to view an organ or body part via a cannula or a portal.

As used herein, the words “proximal” and “distal” refer to directioncloser to and away from, respectively, an operator (e.g., surgeon,physician, nurse, technician, etc.) who would insert a device (e.g., aportal of the present invention) into the patient, such that the distalend of the device is the end that is inserted inside a patient's body,while the end outside the patient's body would be the proximal end.

As used herein, the epicardial surface is the outer surface of theheart. The term epicardial surface is also used to refer to theinnermost of the two layers of pericardium.

The endocardium is the membrane that lines the cavities of the heart andforms part of the heart valves—i.e., the innermost layer of the heart.

Also, as used herein, the pericardial surface is the outer surface ofthe pericardial sac. The pericardium is a double-walled sac thatcontains the heart and the roots of the great vessels.

Also, as used herein, pericardioscopy and/or pericardioscopic refers toendoscopic devices and methods that can provide access to thepericardium and the epicardial (outer) surface of the heart. Cardioscopyand/or cardioscopic, refers to endoscopic devices and methods that canprovide access to the endocardial (inner) surface of the heart. Ingeneral, pericardioscopic and cardioscopic access to the thoracic cavitymay be made via an incision in diaphragm. Or, other types of access maybe used. The procedures performed in and on the heart may be surgical,where surgery encompasses physical manipulation of the heart tissue in asignificant manner. In certain embodiments, surgery comprises makingincisions in the heart tissue. Or, the procedures may involve emplacinga device and/or tool on or in the heart tissue. Or, the procedures maycomprise mapping of electrical current within at least a portion of theheart tissue.

Furthermore, in this specification and the appended claims, the singularforms “a,” “an” and “the” include plural referents unless the contextclearly dictates otherwise. Thus, for example, the term “a lumen” isintended to mean a single lumen or a combination of lumens, “a fluid” isintended to mean one or more fluids, or a mixture thereof.

Methods, Devices and Systems for Endoscopic Access to the Heart

Embodiments of the present invention comprise methods, devices, andsystems for endoscopic access to the heart, including direct endoscopicaccess to the left atrium. The present invention may be embodied in avariety of ways.

In certain embodiments, the present invention may comprise methods toaccess the atrium of a subject so as to perform surgical procedures uponthe atrium. The method may comprise the steps of inserting the distalend of an atrial portal into the pericardium of the subject;manipulating the proximal end of the atrial portal to position thedistal end of the atrial portal at the surface of the atrium;determining an entry location for the atrial portal to be inserted intothe atrium; inserting the atrial portal into the atrium; and securingthe position of the atrial portal in the atrium. In an embodiment, theatrium is the left atrium and the device comprises a left atrial portal.In other embodiments, the atrium is the right atrium, and the devicecomprises a right atrial portal. For each of the embodiments disclosedherein, the atrial portal may access either the right or left atrium asrequired, and as understood by those of skill in the art. Thus, for mostembodiments, reference to the left atrial portal will include an atrialportal that can be used to access a right atrium.

In certain embodiments, a pericardioscopic portal is used in combinationwith the atrial portal. Thus, in certain embodiments, the method maycomprise inserting the atrial portal into a pericardioscopic portal andpositioning the distal end of the pericardioscopic portal at the surfaceof the atrium.

In certain embodiments, at least one of an ultrasound probe, anendoscope, or other imaging device is used in combination with theatrial portal. Thus, in certain embodiments, the method may compriseusing an ultrasound probe positioned at the distal end of the atrialportal to provide an image of body structures present near the distalend of the atrial portal. In an embodiment, a pericardial portal may beused to position an endoscope to be used with the atrial portal. Or, anultrasound probe may be included in the lumen of the pericardial portal.Or, the imaging device may be delivered independently of either theatrial portal or the pericardioscopic portal.

In certain embodiments, the method provides sutures around the opening(defect) made in the wall of the atrium, as a way to secure the atrialportal in the atrium wall. The sutures may be tightened such that theinsertion of the atrial portal into the atrium wall does not result inloss of blood from the atrium. Thus, in certain embodiments, the methodmay comprise providing sutures in the surface of the atrium thatsurround the entry location for the atrial portal and tightening thesutures around the atrial portal upon insertion of the atrial portal inthe atrium to secure the atrial portal in the atrium. In an embodiment,a pericardial portal is used to position tools used to make the sutures.Or, the suturing tools may be included in the lumen of the atrialportal. Or, the suturing tools may be delivered independently of eitherthe atrial portal or the pericardioscopic portal.

The sutures may comprise (or be used in combination with) a pledget, ora plurality of pledgets, or other type of reinforcing element todistribute the pressure from the sutures more evenly on the tissue toreduce injury to the tissue.

In certain embodiments, the method may comprise the use of a tourniquettype device to tighten the sutures that have been emplaced in the atriumwall such that there is a tight seal between the sutures and the atrialportal. Thus, in certain embodiments, the method may comprise providinga tourniquet to tighten the sutures around the atrial portal. Thetourniquet may be positioned adjacent to the atrial portal. In certainembodiments a cardioscopic Rommel tourniquet may be used. Or, othertypes of tourniquets that can be used cardioscopically may be used.Also, in certain embodiments, the tourniquet comprises a suture capturedevice which allows a user with access to the proximal end of thetourniquet to tighten the sutures around the atrial portal so as tosecure the atrial portal in the atrium. In an embodiment, a pericardialportal is used to position the tourniquet and/or the suture capturedevice. Or, the tourniquet and/or the suture capture device may beincluded in the lumen of the atrial portal. Or, the tourniquet and/orthe suture capture device may be delivered independently of either theatrial portal or the pericardioscopic portal.

In certain embodiments, the atrial portal is inserted into the atriumwall by making a small (needle-sized) defect (i.e., 0.1-3 mm, or 0.2 to2 mm, or about 0.5 to 1 mm in size) in the wall and then advancing theatrial portal into the wall through the defect. This type of entry canminimize loss of blood as the atrial portal is inserted into the atriumwall. Thus, in certain embodiments, the step of inserting the atrialportal into the atrium comprises using an introducer needle containedwithin the atrial portal to puncture the atrium wall.

Once the defect has been made in the atrium, a guide wire may beinserted into the atrium. This guide wire may then provide a platformfor insertion of the atrial portal and associated tools into the atrium.Guide wires generally used for such surgical procedures may be employed.For example, in certain embodiments, a 0.014 guide wire (about 0.35 mmin diameter) or a 0.038 guide wire (about 1 mm in diameter) may be used.For example, in certain embodiments, the method may comprise inserting aguide wire through the needle used to make a defect in the atrium, andwithdrawing the needle such that the guide wire is inserted into theatrium at the entry location for the atrial portal. The method mayfurther comprise threading the atrial portal over the guide wire andinto the atrium.

The atrial portal has a diameter that is greater than the diameter of aneedle or a guide wire. Thus, in certain embodiments, the distal tip ofthe atrial portal may comprise a dilating introducer. In certainembodiments, the dilating introducer may be graduated, such that it ismore narrow at the most distal point of the introducer and widens to thecircumference of the main body of the atrial portal at the proximal endof the introducer. Thus, in certain embodiments, the step of insertingthe atrial portal into the atrium comprises inserting a dilatingintroducer positioned at the distal end of the atrial portal into theentry location and pushing the introducer distally into the atrium wallto enlarge the opening at the entry location. Or, other types ofgraduated distal tips may be used to facilitate entry of the atrialportal into the atrium.

There may be a need to secure the atrial portal in the wall of theatrium. In one embodiment, sutures emplaced in the atrium wall can beused to tighten the atrium wall around the circumference of the atrialportal once the portal has been inserted in the atrium wall. Also, incertain embodiments, the distal end of the atrial portal may comprise acap that is configured to assist with securing the atrial portal in theatrium wall. The cap may be made of a rubber or other expandable orinflatable material that can be expanded at least at certain parts ofthe cap so as to prevent the portal from moving distally or proximallyin relation to the atrial wall. Thus, in certain embodiments, the methodmay comprise using a flexible cap positioned on the distal end of theatrial portal to secure the distal end of the atrial portal in theatrial wall. In certain embodiments, at least a portion of the cap canbe expanded laterally away from the central longitudinal axis of theatrial portal. In this way, the cap may increase the tightness of theseal between the outer surface of the atrial portal and the atrium wall.Also, and as described in more detail herein, the cap may, in certainembodiments, comprise a shape that is larger (i.e., has a greatercircumference) on the distal end of the cap then a central portion ofthe cap and/or a proximal portion of the cap when the atrial portal isinserted into the entry location of the atrium. In this way, the cap mayprevent the atrial portal from being pulled proximally out of theatrium. Also, in certain embodiments, the cap may comprise an expandableor extendable portion on the proximal end of the cap that can be used toprevent the atrial portal from being pushed more distally into theatrium.

The atrial portals of the present invention can provide direct access toeither the left atrium or the right atrium and portions of the heartthat can be accessed from the left or right atrium. For example, oncethe atrial portal is in position in the left atrium, the left or rightatrium endocardium, mitral valve, left ventricle, aorta, vessels leadingto or from the heart, and other structures may be accessed. Also, thepericardial portals of the present invention may be used to provideaccess to the epicardial surface or the surface of the pericardial sac.Thus, in certain embodiments, the method may comprise inserting a toolin the atrium using the atrial portal and in some cases the pericardialportal of the present invention. Alternatively, the present inventionprovides methods to access either the epicardial surface or thepericardial surface using a pericardial portal.

In this way, using the atrial portals and the pericardial portals of thepresent invention, therapeutic procedures may be performed on the heart,e.g., by inserting tools to perform such therapeutic procedures into theatrium via the atrial portal or by accessing the pericardial surface orthe epicardial surface using a pericardial portal.

There may be a variety of methods used to position a tool that has beeninserted into the heart via an atrial portal at the correct location inthe heart. In certain embodiments, the tool may be threaded over a guidewire that extends from the proximal end of the atrial portal (i.e., thepart of the atrial portal that exits the body) to the distal end of theatrial portal (i.e., the part of the atrial portal that is inserted intothe atrium).

A variety of tools may be inserted into the atrium for use intherapeutic procedures in either the atrium or other structures andregions of the heart. Also, a variety of tools may be employed on theepicardial (or pericardial) surface for use in therapeutic procedures oneither the atrium or other structures and regions of the heart.

In certain embodiments, the tool may comprise an ablation element thatis used to ablate a portion of the atrium or another part of the heartand/or vessels leading to or from the heart (e.g., a vessel leading intoor out of the left atrium). In an embodiment, such ablation may be usedto treat atrial fibrillation (AF). Alternatively, such ablation may beused to reduce a valve from a first extended configuration to a smallerconfiguration.

In other embodiments, the tool may comprise an electrode that is used tomeasure electrical activity at a site in the atrium or another region ofthe heart.

Or, the tool may comprise an inner cannula for implanting at least oneof a stent, or a valve in the heart. For example, in certain embodimentsof using an atrial portal, the method may comprise manipulating theproximal end of an inner cannula and/or catheter comprising a stentand/or valve prosthesis to position the stent and/or valve prosthesiswithin a vessel leading into or from the atrium. The inner cannulaand/or catheter for implanting a valve and/or a stent may, in certainembodiments, comprise an expandable member to expand a diseased valve orvessel in the subject prior to emplacement of the therapeutic valveand/or stent. Also, in some embodiments, the inner cannula and/orcatheter may comprise a capture device that can be positioned adjacentto the sight of implantation of the valve and/or the stent to trapdebris that may be loosened from the vessel or the valve during theimplantation procedure.

In other embodiments, an atrial portal of the present invention may beused for delivery of devices that can be used for mitral valvereduction. Thus, in certain embodiments, the method may compriseimplanting at least two barbed needles near a valve in need of reductionand pulling distally (e.g., using sutures attached to the proximal endof the barbed needles) on the two implanted barbed needles to reduce thecircumference of the valve. For example, an inner catheter or cannulacomprising a barbed needle attached to a suture may be threaded throughan atrial portal and implanted in the posterior annulus of the mitralvalve. In an embodiment, the barbed needle may be contained within anintroducer prior to positioning in the mitral valve. Also, in anembodiment, a sheath that extends proximally and that covers the suture,but provides stiffness, may be used to push the barbed needle throughthe introducer and into the tissue.

Embodiments of the present invention also comprise devices forcardioscopic and pericardioscopic access of the heart. In certainembodiments, the present invention comprises device for accessing anatrium of the heart in a subject so as to perform a therapeuticprocedure upon the atrium or to access other regions of the heart. Thedevice may comprise an atrial portal having a configuration such thatthe distal end of the atrial portal can provide cardioscopic access theatrium by insertion of the distal end of the portal into the atriumwhile the proximal end of the atrial portal can extend to outside of thesubject. In an embodiment, the portal is fashioned to access the leftatrium. Or, the portal may be fashioned to access the right atrium. Foreach of the embodiments disclosed herein, the atrial portal may accesseither the right or left atrium as required, and as understood by thoseof skill in the art. Thus, for most embodiments, reference to the leftatrial portal will include an atrial portal that can be used to access aright atrium.

Yet other embodiments of the present invention comprise a pericardialportal. In certain embodiments, the pericardial portal may be fashionedto have a configuration such that the distal end of the pericardialportal can provide pericardioscopic access the pericardium orepicardium, while the proximal end of the pericardial portal can extendto outside of the subject. In an embodiment, the pericardial portal maybe fashioned to have a configuration such that when an atrial portal isinserted into the lumen of the pericardial portal, the distal end of theatrial portal can access the atrium while the proximal end of the atrialportal can extend to outside of the subject.

In certain embodiments, the present invention may comprise a system. Forexample, in certain embodiments, the system may comprise an atrialportal in combination with a tool to be used with the atrial portal. Or,the system may comprise an atrial portal to be used in combination witha pericardial portal. Or, the system may comprise a pericardial portalin combination with therapeutic tool to be used with the pericardialportal.

In certain embodiments, the devices and/or systems of the presentinvention may comprise an imaging tool. In certain embodiments, theimaging tool may be an ultrasound probe or an endoscope to provide animage of body structures present near the distal end of the atrialportal or the pericardial portal. The endoscope may be positioned nearthe distal end of the atrial portal to provide a visual image of bodystructures present near the distal end of the atrial portal. In anembodiment, a pericardial portal is used to position the endoscope orthe ultrasound probe. Or, an ultrasound probe may be included in thelumen of the atrial portal.

In certain embodiments, the devices and/or systems of the presentinvention comprise a tool to provide sutures around the opening (defect)made in the wall of the atrium, as a way to secure an atrial portal inthe atrium wall. The sutures may be tightened such that the insertion ofthe atrial portal into the atrium wall does not result in loss of bloodfrom the atrium. In an embodiment, a pericardial portal comprises thetool configured for emplacing sutures in the atrial wall to secure theatrial portal in the atrium. Or, the suturing tools may be included inthe lumen of the atrial portal. Or, the suturing tools may be deliveredindependently of either the atrial portal or the pericardioscopicportal. For example, in certain embodiments of the devices and systemsof the present invention, the sutures are of a configuration so as tosurround the atrial portal upon insertion of the atrial portal in theatrium such that tightening the sutures around the atrial portal securesthe atrial portal in the atrium.

The sutures may comprise (or be used in combination with) a pledget, ora plurality of pledgets, or other type of reinforcing element todistribute the pressure from the sutures more evenly on the tissue toreduce injury to the tissue.

In certain embodiments, the devices and/or systems of the presentinvention may comprise a tourniquet type device to tighten the suturesthat have been emplaced in the atrium wall such that there is a tightseal between the sutures and the atrial portal. The tourniquet may bepositioned adjacent to the atrial portal. In certain embodiments acardioscopic Rommel tourniquet may be used. Or, other types oftourniquets that can be used cardioscopically may be used. Also, incertain embodiments, the tourniquet comprises a suture capture devicewhich allows a user with access to the proximal end of the tourniquet totighten the sutures around the atrial portal so as to secure the atrialportal in the atrium. In an embodiment, the tourniquet and/or the suturecapture device is provided as part of a pericardial portal. Or, thetourniquet and/or the suture capture device may be included in the lumenof the atrial portal. Or, the tourniquet and/or the suture capturedevice may be delivered independently of either the atrial portal or thepericardial portal.

In certain embodiments of the devices and systems of the presentinvention, the atrial portal is inserted into the atrium wall by makinga small (needle-sized) defect (i.e., 0.1-3 mm, or 0.2 to 2 mm, or about0.5 to 1 mm in size) in the wall and then squeezing the atrial portalinto the wall through the defect. This type of entry can minimize lossof blood as the atrial portal is inserted into the atrium wall. Thus, incertain embodiments, atrial portal further comprises a needle within thelumen of the atrial portal, wherein the needle is configured to puncturethe atrium so as to provide an opening for insertion of the left portalinto the atrium.

Once the defect has been made in the atrium, a guide wire may beinserted into the atrium. This guide wire may then provide a platformfor insertion of the atrial portal and associated tools into the atrium.Guide wires generally used for such surgical procedures may be employed.For example, in certain embodiments, a 0.014 guide wire (about 0.35 mmin diameter) or a 0.038 guide wire (about 1 mm in diameter) may be used.For example, in certain embodiments, the atrial portal further comprisesa guide wire, wherein the guide wire is configured to provide a path forinsertion of the atrial portal into the atrium by threading the atrialportal over the guide wire and into the atrium, and withdrawing theneedle such that the guide wire is inserted into the atrium at the entrylocation for the atrial portal. The method may further comprisethreading the atrial portal over the guide wire and into the atrium.

The atrial portal may generally have a diameter that is greater than thediameter of a needle or a guide wire. Thus, in certain embodiments ofthe devices and systems of the present invention, the distal tip of theatrial portal may comprise a dilating introducer. In certainembodiments, the dilating introducer may be graduated, such that it ismore narrow at the most distal point of the introducer and widens to thecircumference of the main body of the atrial portal at the proximal endof the introducer. Thus, in certain embodiments, the distal end of theatrial portal comprises a dilating introducer, wherein the dilatingintroducer is configured so as to be inserted in an opening in theatrial wall so as to enlarge the opening of the atrial wall forinsertion of the atrial portal into the atrium. Or, other types ofgraduated distal tips may be used to facilitate entry of the atrialportal into the atrium.

There may be a need to secure the atrial portal of the devices andsystems of the present invention in the wall of the atrium. In oneembodiment, sutures emplaced in the atrium wall can be used to tightenthe atrium wall around the circumference of the atrial portal once theportal has been inserted in the atrium wall. Alternatively oradditionally, in certain embodiments of the devices and systems of thepresent invention, the distal end of the atrial portal may comprise acap that is configured to assist with securing the atrial portal in theatrium wall. The cap may be made of a rubber or other material that canbe expanded at least at certain parts of the cap so as to prevent theportal from moving distally or proximally in relation to the atrialwall. Thus, in certain embodiments, the cap can be expanded laterallyaway from the central longitudinal axis of the atrial portal. In certainembodiments, at least a portion of the cap can be expanded laterallyaway from the central longitudinal axis of the atrial portal. In thisway, the cap may increase the tightness of the seal between the outersurface of the atrial portal and the atrium wall. Also, and as describedin more detail herein, the cap may, in certain embodiments, comprise ashape that is larger (i.e., has a greater diameter) on the distal end ofthe cap then at a central portion of the cap and/or a proximal portionof the cap when the atrial portal is inserted into the entry location ofthe atrium. In this way, the cap may prevent the atrial portal frombeing pulled proximally out of the atrium. Also, in certain embodiments,the cap may comprise an expandable or extendable portion on the proximalend of the cap, wherein the extendable portion is configured to bepositioned on the outer atrial surface so as to prevent the atrialportal from being inserted into the atrium further than the length ofthe cap.

As noted above, the atrial portals of the devices and systems of thepresent invention can provide direct access to either the left atrium orthe right atrium and portions of the heart that can be accessed from theleft or right atrium. Also, the pericardial portals of the presentinvention may be used to provide access to the epicardial surface or thesurface of the pericardial sac. Thus, using the atrial portals and thepericardial portals of the present invention, therapeutic procedures maybe performed on the heart, e.g., by inserting tools to perform suchtherapeutic procedures into the atrium via the atrial portal or byaccessing the pericardial surface or the epicardial surface using apericardial portal.

There may be a variety of methods used to position a tool that has beeninserted into the heart via an atrial portal of the devices and systemsat the correct location in the heart. In certain embodiments, the atrialportal or pericardial portal may comprise a guide wire for positioningtools on or in the heart. Thus, in certain embodiments of the devicesand systems of the present invention, the tool is configured to bethreaded over a guide wire that extends from the proximal end of theatrial portal (and/or the pericardial portal) to the distal end of theatrial portal and/or the pericardial portal. The tool may then bethreaded over the guide wire that extends from the proximal end of theatrial portal (i.e., the part of the atrial portal that exits the body)to the distal end of the atrial portal (i.e., the part of the atrialportal that is inserted into the atrium). Or, the tool may be threadedover a guide wire that extends from the proximal end of the pericardialportal (i.e., the part of the pericardial portal that exits the body) tothe distal end of the pericardial portal (i.e., the part of thepericardial portal that is near the heart).

Using the devices and systems of the present invention, a variety oftools may be inserted into the atrium for use in therapeutic proceduresin either the atrium or other structures and regions of the heart. Also,a variety of tools may be employed on the epicardial (or pericardial)surface for use in therapeutic procedures on either the atrium or otherstructures and regions of the heart.

Thus, in certain embodiments of the devices and systems of the presentinvention, the tool may comprise an ablation element that is used toablate a portion of the atrium or another part of the heart and/orvessels leading to or from the heart (e.g., a vessel leading into or outof the atrium). In an embodiment, such ablation may be used to treatatrial fibrillation (AF), atrial tachycardia or flutter, as well asventricular arrhythmias such as ventricular tachycardia. Alternatively,such ablation may be used to reduce a valve from a first extendedconfiguration to a smaller configuration.

In other embodiments, the tool may comprise an electrode that is used tomeasure electrical activity at a site in the atrium or another region ofthe heart.

Or, the tool of the devices and systems of the present invention maycomprise an inner cannula for implanting at least one of a stent and/ora valve prosthesis in the heart. For example, in certain embodiments ofusing an atrial portal, the method may comprise manipulating theproximal end of the inner cannula and/or catheter to position the stentand/or valve prosthesis within a vessel leading into or from the atrium.The inner cannula for implanting a valve and/or a stent may, in certainembodiments, comprise an expandable member to expand a diseased valve orvessel in the subject prior to emplacement of the therapeutic valveand/or stent. Also, in some embodiments, the inner cannula and/orcatheter may comprise a capture device that can be positioned adjacentto the sight of implantation of the valve and/or the stent to trapdebris that may be loosened from the vessel or the valve during theimplantation procedure.

In other embodiments of the devices and systems of the presentinvention, the atrial portal may be used for delivery of devices thatcan be used for mitral valve reduction. Thus, in certain embodiments,the method may comprise implanting at least two barbed needles near avalve in need of reduction and pulling distally on the two implantedbarbed needles (e.g., using sutures attached to the barbed needles) toreduce the circumference of the valve. For example, an inner catheter orcannula comprising a barbed needle attached to a suture may be threadedthrough the atrial portal and implanted in the posterior annulus of themitral valve. In an embodiment, the barbed needle may be containedwithin an introducer prior to positioning in the mitral valve. Also, inan embodiment, a sheath that extends proximally and that covers thesuture, but provides stiffness is used to push the barbed needle throughthe introducer and into the tissue.

Atrial Portal Procedures and Devices

In certain embodiments, the present invention relates to atrial portalprocedures and devices for performing such procedures. The atrial portalmay, in certain embodiments, be used in combination with apericardioscopic portal which can provide access to the pericardium forthe atrial portal and other devices. Alternatively and/or additionally,the atrial portal may be used with a pericardioscopic cannula.

There is often, however, a need to directly access the left atriumwithout using a trans-septal approach. Thus, certain embodiments are ofthe methods, devices and systems may be used to directly access the leftand/or the right atrium.

For example, in certain embodiments, after positioning a left atrialportal and/or a pericardial portal inside the pericardial sac, the leftatrium may be directly visualized such that the posterior left atriumwith associated left and right inferior pulmonary veins can beidentified. The appropriate site for insertion of the left atrial portalin the atrium (i.e., the entry location) may differ depending upon theprocedure to be performed within the left atrium. For example, mitralvalve procedures may require differing placement than ablativeprocedures. After identifying the appropriate entry location for theleft atrial portal, an endoscope (e.g., contained within a pericardialportal) may be positioned for optimal visualization of the left atrialportal entry location.

At this point, a suture may be positioned near the entry location in theatrial wall. As discussed in more detail herein, the suture (or sutures)may be used to secure the atrial portal in the heart wall. Also, thesutures may be used to close the entry location (i.e., the orifice madein the left atrium) after the atrial portal is removed.

In certain embodiments, a suture or sutures may be positioned around thecircumference of the entry location. For example, in certainembodiments, the suture or sutures may be positioned in a purse stringmanner as illustrated in detail herein. Or, other arrangements and/orsuturing techniques may be used. In certain embodiments, the suture isused in combination with pledgets. Such pledgets can provide support forthe sutures and also provide a surface to abut the left atrial portal soas to secure the left atrial portal in the atrium wall.

The size of the suture, and the size of the entry location for theatrial portal may be varied as required by the size of the atrialportal. For example, where a purse-string technique is employed, thepurse-string may have pledgets on at least two sides and may beconfigured to surround the entry location appropriately sized for theatrial portal. As described in more detail below, a atrial portal needleand/or introducer may then be positioned at the location chosen forinsertion of the atrial portal (i.e., the entry location), and theneedle and/or introducer then inserted directly into the left or rightatrium in the center of the purse-string suture.

In certain embodiments, insertion of a needle (i.e., an introducerneedle) into the atrium may be performed after administering heparin.Also, in certain embodiments, insertion of an introducer needle into theatrium may be performed with the patient in Trendelenburg position tomaintain elevated atrial pressure during cannulation. Once the tip ofthe introducer needle is in the atrium, a guide wire can be positionedinto the atrium through the needle. This wire may be used to maintainaccess to the atrium. In certain embodiments, the guide wire may be along flexible J-tipped guide wire with distal flexible tip. Or, otherguide wires may be used.

In certain embodiments, and as described in more detail herein, theatrial portal may be placed in position through the atrial wall over adilating introducer (e.g., a graduated sheath). In certain embodiments,the dilating introducer may have a flexible tip. For example, in certainembodiments, a dilating introducer may be placed over a guide wire thathas been inserted in the atrium, and pushed into the atrial wall toexpand the opening in the atrial wall to allow placement of a leftatrial portal through the wall.

In certain embodiments, and as described in more detail herein, theatrial portal may comprise an expandable member or members that may beused to secure the distal end of the atrial portal into the atrial wall.The expandable member may, in alternate embodiments, be expanded withair or another gas, or a fluid (e.g., saline). In certain embodiments,the expandable member may comprise a balloon or inflatable member. In anembodiment, the expandable member or members is fashioned as a cap atthe distal end of the atrial portal.

In certain embodiments, the atrial portal (and pericardial portal) andparts of the atrial portal and/or pericardial portal that contact theinterior of the atrium or the heart are heparin coated. In certainembodiments, the expandable member or members is heparin coated. Incertain embodiments, the dilating sheath and atrial cap is heparincoated.

For example, there may be an expandable member positioned at, or veryclose to the distal end of the atrial portal, such that when the atrialportal is inserted into the atrium, this expandable member constitutesan internal expandable member. In this way, once the atrial portal is inposition, the internal expandable member may be inflated (e.g., withsaline) to maintain traction on the internal surface of the atrial wall,such that the atrial portal cannot be pulled proximally out of theopening once the internal expandable member has been expanded.

In certain embodiments, the atrial portal may also comprise an externalinflatable and/or expandable member (i.e., an expandable member that ispositioned external to the atrium when the atrial portal is inserted inthe atrial wall). The external inflatable and/or expandable member maybe positioned more proximally along the atrial portal such that when theatrial portal is inserted into the atrium, this expandable memberconstitutes an external expandable member. In this way, once the atrialportal is in position, the external expandable member may be inflated(e.g., with saline) to maintain traction on the external surface of theatrial wall, such that the atrial portal cannot be pushed distallyfurther into the opening once the internal expandable member has beenexpanded. In this way, the internal expandable member and the externalexpandable member can secure the atrial portal in the atrial wall. In anembodiment, the external expandable member is an inflatable member.Alternatively, solid flaps or other elements that extend from the capmay be used.

In an embodiment, both the internal expandable member and the externalexpandable member are part of a cap at the distal end of the atrialportal.

In certain embodiments, the atrial portal, introducer needle, and thedilating introducer may be used as a single unit to insert the atrialportal into the atrium. The single unit may provide increased stabilityfor procedures that have significant lateral or horizontal torque placedon the device. In this embodiment, there may be a tapered suture tiearea on the distal end of the atrial portal for securing the device tothe atrium. After a securing suture (e.g., purse-string suture) has beenplaced, the unit (i.e., atrial portal, introducer needle and dilatingintroducer) can be positioned (e.g. under direct visual access byendoscopy) onto the surface of the atrium, and within the identifiedentry location (e.g., in the center of the purse-string suture) with theneedle withdrawn into the dilator. The needle can be advanced into theatrium. Next, a guide wire may be advanced into the atrium. The needlemay then be partially withdrawn and the entire unit advanced to allowthe dilating introducer and distal portion of the atrial portal to beinside the atrial cavity. The purse string suture may then tightened, asis described in more detail herein, thereby securing the atrial portalto the left atrium. In an embodiment, expandable members on the distalend of the atrial portal may be inflated, thereby securing the distaltip of the atrial portal into the left atrium. The guide wire,introducer needle, and dilating introducer may then be withdrawn.

At this point, i.e., once the atrial portal is introduced into theatrium, various tools and/or devices may be inserted into the atrium.

In certain embodiments of the devices, methods and systems of thepresent invention, heparin is administered to prevent thrombus formationwithin the atrium. For example, a left atrial portal can be perfusedwith heparinized saline to prevent thrombus formation within the device.

Atrial Portal Procedures

a. Ablation Procedures in the Left Atrium

Currently, performing ablation in the left atrium is a difficultprocedure, that requires extensive training to perform, and that is notwithout significant risk to the patient, especially for the targetedpatient population (i.e., patients who have cardiac disease). Access tothe left atrium during percutaneous catheter ablation typically has beenperformed by passing a needle across the atrial septum (i.e., the wallbetween the left and right atrium), positioning a wire from the right tothe left atrium, and then dilating an opening between the two atrialarge enough to allow manipulation of catheters inside the left atrium.This can be a challenging procedure, and consequently, is performed byrelatively few physicians. For example, ablation procedures to treatatrial fibrillation generally require two atrial septal defects: one forthe ablation catheter and another for an interrogation electrode. At thecompletion of this type of procedure, the defects in the septum remain,allowing the inappropriate flow of blood between the left atrium and theright atrium until the defect closes, which generally requires about twoto four months. Additionally, repeat ablation procedures using thetrans-septal approach can be associated with increased complications dueto the scar tissue that has formed from prior trans-septal access.

Embodiments of the devices, methods and systems of the present inventionallow for direct cannulation of the left atrium to perform ablationprocedures. Direct cannulation of the left atrium avoids the need tocross the intra-atrial septum, thereby eliminating the technicalchallenge of crossing the septum to gain access to the left atrium.Also, the risk of post-procedure atrial septal defects is significantlyreduced, as no defect is made in the septum during the surgery.

Additionally, direct cannulation of the left atrium allows the placementof larger ports and more sophisticated instruments into the left atrium.Once the left atrial portal is in place, a physician can insert anablation tool to perform procedures (e.g., ablative procedures to treatatrial fibrillation) inside of the heart with less risk and lesscomplexity.

b. Heart Failure Sensors

In patients who have a failing heart, implantation of therapeuticdevices such as pacemakers and/or implantable cardioverterdefibrillators (ICDs) is a generally common treatment, as such devicesmay ameliorate symptoms so as to delay and/or prevent the patientrequiring a ventricular assist device. Current devices may incorporate“heart failure” sensors, which can for example, measure transthoracicimpedance as a measure of worsening heart failure. Devices that measuredirect pressure have been developed, although these devices primarilymeasure pressure in the right atrium, right ventricle or rightventricular outflow tract and infer changes in right sided pressure as areference to left sided pressures. As a result, there is not always be adirect comparison of left sided filling pressures.

The devices, methods and systems of the present invention may, incertain embodiments, be used for measurement of left atrial pressure.Although measurement of left atrial pressure by a trans-septal puncturefrom a superior subclavian approach has been explored, the procedure iscomplicated and therefore rarely, if ever, performed. For example, thetrans-septal approach adds another “lead” within the vascularstructures, increasing the risk for stenosis or occlusion of the vein.Also, the vein used for implantation may not be of appropriate size toallow placement of all of the required leads. For example, many implantsuse a biventricular device which has three leads, and thus, require alarge vein for introduction.

Direct cannulation of the left atrium using the devices, methods andsystems of the present invention can eliminate the difficulty ofcrossing the intra-atrial septum from the superior approach. Directcannulation can reduce difficulties associated with emplacing multipleleads within the vascular structures. Using a left atrial portal of thepresent invention to provide access to the left atrium can allowplacement of left atrial pressure sensors which have a greater accuracyin assessing left sided filling pressures. The lead can then be tunneledback either from an epigastric access, or via the pericardium in asuperior fashion to the generator pocket (generally emplacedsubcutaneously).

In certain embodiments, the devices, methods and/or systems of thepresent invention may include a sensor “button” that uses a pressuresensor and a wireless communication with the device. In this way, remotemonitoring of the atrial pressure may be performed. Also, combinationlead therapies that contain sensors and the ability to pace the leftatrium may be provided using the devices, methods and/or systems of thepresent invention.

c. Left Atrial Appendage Therapies

Atrial fibrillation is responsible for about 15% of all strokes(Sandercock et al., BMJ 1992; 305:1460-5; Wolf et al., Am. Heart J.,1996; 131:790-5; and Kannel et al., Am. J. Cardiol., 1998; 82:2 N-9N)and evidence suggests that about 90% of these strokes are related tothrombus formation in the left atrial appendage (Aberg et al., Acta Med.Scand., 1969:185:373-9; Stoddard et al., J. Am. Coli Cardiol. 1995;25:452-9; and Blackshear and Odell, Ann. Thorac. Surg., 1996:61:755-9).The PLAATO® device has been developed to percutaneously close the leftatrial appendage (LAA) and exclude it from intra-cardiac circulationthereby potentially reducing the risk of embolic thrombus migration andstroke. This is less invasive than cardiac surgical removal of the LAAand may decrease the risk of stroke in those patients with atrialfibrillation (AF). However, to emplace the PLAATO® device, physiciansmust gain access to the left atrium via the atrial septum, which, asdescribed previously, can be associated with complicating factors.

The devices, methods and systems of the present invention can, incertain embodiments, provide direct access to the left atrium forplacement of these devices. Additionally, because the left atrialappendage can be directly visualized using pericardioscopy, procedures,instrumentation and devices for emplacing an occlusive device around thebase of the LAA from the epicardium can be facilitated with endocardialmanipulation of the LAA. For example, the left atrial portal can beadjusted in size to accommodate the device being utilized. Theadditional ability to access the LAA via the pericardial sac and fromthe endocardial aspect may decrease the complexity of LAA devicedeployment. Also, ability to access the LAA via the pericardial sac maydecrease the complexity of LAA occlusion and excision surgically.

d. Valve Therapies

There is a need to improve methods for treating both mitral and aorticvalve diseases. Currently, endovascular placement of valves, either bypercutaneous femoral access or trans-apical access may be used.

The devices, methods and systems of the present invention may be used toprovide access to the left atrium in a minimally invasive fashion, suchthat valve disorders may be treated without arresting the heart. Forexample, in one embodiment, the left atrial portal can be positioned andwith the use of fluoroscopy or other types of imaging (e.g.,intracardiac and epicardial ultrasound), positioned such that valves inthe heart (e.g., the mitral and aortic valves) are visualized andaccessed to perform structural repairs.

For example, using the devices, methods and/or systems of the invention,the mitral valve annulus may be reduced internally by positioning areducing device, such as a band, a ring or suture material in theposterior mitral valve annulus. In this way, one can reduce the annulusand improve mitral annular dilatation which causes mitral valveregurgitation. Such direct manipulation of the posterior mitral valveannulus may be performed using a left atrial portal of the presentinvention. In certain embodiments, imaging guidance, either via anultrasound probe positioned within the left atrial portal or viaepicardial ultrasound, is used to visualized the valve. For example,using ultrasound, the amount of reduction can be determined in real timebecause the heart is beating and functioning during the reduction. Thedegree of reduction can be adjusted based on the improvement of thevalve function. Using the devices, methods and systems of the presentinvention such valve therapies may be performed on the beating heart,endoscopically, and without cardiopulmonary bypass.

Additionally or alternatively, placement of expandable mitral valve andaortic valve prosthesis may be performed using the devices, methods andsystems of the present invention. In an embodiment, after the leftatrial portal is positioned in the left atrial wall, a guide wire withinthe lumen of the left atrial portal may be threaded through the leftatrium and into the valve to be treated. Next, devices (e.g.,replacement valves) may be positioned in the valve as required.Alternatively, devices necessary to deploy percutaneous valve technologythrough the left atrial portal may be used. Again, using the devices,methods and systems of the present invention such valve therapies may beperformed on the beating heart, endoscopically, and withoutcardiopulmonary bypass.

e. Cardiac Assist Devices

Patients with acute post-cardiotomy heart failure (heart failure afteropen heart surgery) or chronic, end-stage heart failure may requiremechanical support with an “artificial heart”. These devices, like theNOVACOR® (World Heart, Salt Lake City, Utah) or HEARTMATE® (Thoratec,Pleasanton, Calif.) help the heart pump blood when it is unable to keepup with the demands of the body. Traditionally, placement of thesedevices has required median sternotomy and cardiopulmonary bypass.Cannulas to connect the pump to the heart must be inserted into theright atrium and pulmonary artery for right heart support and in theleft atrium and aorta for left heart support.

The devices, methods and systems of the present invention may be used toprovide access to the left or right atrium in a minimally invasivefashion, such that the left atrium can be cannulated for access by anartificial heart. For example, using the devices, methods and systems ofthe present invention, a cannula may be placed in the left atrium todrain blood from the lungs into a heart pump. Also using the devices,methods and systems of the present invention, another return cannula orbypass graft may be inserted into the femoral artery, the subclavianartery, the aorta, or other artery. The blood may then be pumped fromthe left atrium to the systemic arterial system with the left sidedcardiac assist device, a “blood pump” positioned outside the heart.

In yet other embodiments, the devices, methods and systems of thepresent invention may be used to insert a small, tubular centrifugalpump through the left atrium and into the ascending aorta. By placingthis type of pump in the left atrium or left ventricle, blood can bepumped from the left atrium and left ventricle out the aorta to supportthe left heart. The entire pump can be contained within the failingheart as a “bridge to recovery” to be removed when the cardiac functionrecovers, or as a “bridge to transplantation” to be removed upon cardiactransplantation. The IMPELLA® device (Abiomed, Danvers, Mass.) is anexample of such device.

Because such centrifugal pumps are currently emplaced via percutaneousaccess, there may be size constraints on the size of the pump that canbe used as the pump must be of a caliber small enough to fit through thefemoral artery. Such limitations on the size of the pump can result inlimitations on the flow rate that can be achieved. Using the devices,methods and systems of the present invention, a larger device can beplaced through the left atrium, thereby allowing higher flow rates andadded cardiac support.

Alternatively, the devices, methods and systems of the present inventionmay be used to emplace a similar centrifugal pump within the rightatrium and right ventricle to pump blood from the right atrium and rightventricle out the pulmonary artery to the lungs.

Emplacement of Cardioscopic Atrial Pursestring (CAP)

The atrial portal of the present invention provides a conduit for directaccess to the atrium. In order to maintain hemostasis and prevent airentrainment when using the atrial portal for surgical access to theheart, the present invention comprises devices, methods and systems tosecure the atrial portal in the wall of the atrium in an manner suchthat blood is not lost from the atrium via the incision used forinsertion of the atrial portal in the left atrium. As described above, asuture may be positioned near the entry location in the atrial wall. Thesuture (or sutures) may be used to secure the atrial portal in the heartwall. Also, the suture may be used to close the entry location (i.e.,the orifice made in the atrium) after the atrial portal is removed.

In certain embodiments, a suture (or sutures) may be positioned aroundthe circumference of the entry location to seal the atrial tissue aroundthe device. For example, in certain embodiments, a suture may bepositioned in a purse string manner. In certain embodiments, thepurse-string suture can be placed with traditional endoscopic needledrivers, or with an automated needle driver (Endostitch, Covidian,Dublin, Ireland). The purse-string also occludes the opening in the leftatrium at procedure completion.

In certain embodiments, the present invention comprises devices, methodsand systems for placing the purse-string automatically. For example, insome embodiments, the cardioscopic atrial purse string (CAP) device maybe placed over the atrial portal and advanced to the atrial surface.Upon deployment, a suture on a needle may then be passed into the atrialepicardium, and then the suture may be passed outward (i.e., out of theatrial wall) to be retrieved. By deploying two to four needles into themyocardium in a circular pattern, the purse-string may be developed andthe retrieved ends can be used to secure the atrial portal to the leftatrial epicardial surface. As the purse-string is tightened, by pullingproximally (i.e., away from the heart) the atrial wall may be tightenedaround the atrial portal, thereby preventing loss of blood from theatrium, and the entry of air into the heart.

Upon completion of the surgical procedure, and removal of the atrialportal, the suture may be further tightened (again by pulling thesutures distally) and the strings tied to permanently secure the defectin the atrium.

Pericardial Portal

Other embodiments of the present invention may comprise a pericardialportal. Similar to the atrial portal, the pericardial portal can provideaccess to the pericardial space. As described in more detail herein,such access can allow for insertion of other devices (e.g., surgicaltools, electrodes, ablation elements and the like) into the pericardialspace, as for example, for use with a atrial portal. As described inmore detail herein, in certain embodiments, the pericardial portalallows direct access, without continuous visualization, to theepicardial surface of the heart.

In an embodiment, the distal end of the pericardial portal is shaped tofacilitate positioning and securing of the portal on the cardiac side ofthe pericardium. In certain embodiments, the distal end is notcompletely flush along the entire circumference, but is tapered suchthat it extends outward for at least part of the circumference. Also, incertain embodiments, the pericardial portal has a substantiallyflattened distal end.

In certain embodiments, the portal may have side access ports that allowlateral access into the pericardial space. These side ports may includeradiographic markings to facilitate positioning the side ports in thepericardial space.

The pericardial portal may be inserted by the surgeon into the patientvia the diaphragm either at the subxyphoid location or at thetransdiaphragmatic location in the central tendon of the diaphragm. Or,other routes for inserting the pericardial portal may be used dependingupon the procedure to be performed.

Once in place, direct access inside the pericardial sac may allowvarious epicardial procedures to be performed. In addition tofacilitating procedures performed with the atrial portal, suchprocedures may include epicardial mapping and ablation, epicardialimaging (ultrasound, direct visualization using flexible scopes),placement of epicardial pacing leads and other epicardial technologies.The pericardial portal significantly reduces the concern for cardiacinjury, while allowing pericardial access using existing methods andinstrumentation. Using the pericardial portal of the present inventioncan allow for improved manipulation of cannulas and other devices in thepericardial sac or the heart.

Examples of therapies that may be performed using the pericardial portalof the present invention include the following therapeutic procedures.

a. Pacing Therapies

Pacing in patients with sick sinus syndrome is usually performed fromthe right atrium by endocardial/transvenous lead placement. However,using this approach, intra-atrial conduction delay may prevent correctleft atrial/left ventricular synchrony. Such delay may lead toinadequate left ventricular filling and reduced cardiac output.

Pacing of the left atrium can restore this synchrony which may be ofsignificant benefit in the heart failure patient. For example, it hasbeen shown that pacing of the left atrium can reduce acute episodes ofatrial fibrillation after cardiac surgery. Additionally, it is believedthat left atrial pacing may also help prevent long-term episodes ofatrial fibrillation.

Currently, left atrial pacing may be achieved by placing leads on theepicardial surface of the left atrium at the time of open heart surgery,or during transvenous lead placement into the coronary sinus. However,it has been found that the transvenous approach (using either active orpassive fixation leads) can have an increased risk for dislodgement ofthe leads. Also, there may often be a lack of suitable veins to the leftatrium off the coronary sinus, thereby resulting in the need forsurgical placement by thoracotomy or sternotomy (i.e., cutting into thepleural cavity or through the breast bone).

Biventricular pacing devices may be required for patients with advancedheart failure. Such biventricular pacing devices generally requireplacement of leads on the mid-lateral left ventricle in a vein off thecoronary sinus from a transvenous approach. The anatomy of the coronarysinus is variable and may not have adequate veins in the mid-lateralposition, or the veins may contain a stenosis, or have significanttortuosity so as to prevent placement of a left ventricular pacing lead.Surgical placement of a left ventricular lead may be performed, butrequires a thorascopic or thoracotomy approach.

Also, pediatric patients who need pacing therapies usually requireepicardial lead placement. Such epicardial leads are generally placedusing a thoracotomy with most leads placed on the right atrium and rightventricle. Chronic right ventricular pacing can lead to left ventriculardysfunction in a subset of patients.

As described in more detail herein, in various embodiments of thedevices, methods and systems of the present invention, the pericardialportal of the present invention may be used for placement of leads onthe epicardial surface of the heart. Use of the pericardial portal andassociated methods and systems of the present invention can allow forplacement of leads where currently lead placement technologies arelimited by lack of suitable anatomy and eliminates the need for largeincisions in the chest (e.g., thoracotomy).

b. Epicardial Ablation

Arrhythmias may have epicardial foci that are unable to be ablated froman endocardial approach. This leaves the option for either medicaltherapy or epicardial ablation. Epicardial ablation is currentlyperformed only at specialized centers primarily due to the technicaldifficulties in gaining access to the pericardium. Current techniqueshave an increased risk for epicardial vascular damage or chamberperforation due the lack of significant space between the pericardiumand the heart.

As described in more detail herein, in various embodiments of thedevices, methods and systems of the present invention, the pericardialportal of the present invention may be used to provide access for anelectrophysiologist to perform epicardial ablation without the increasedrisk currently associated with pericardial access.

c. CorCap

The CorCap device is a mesh sock that may be placed on the epicardialsurface of the heart to restrict the overall volume of the heart so asto treat heart failure which can result from dilation of the heart. TheCorCap device does not require suturing to the epicardium, but doesrequire access to the heart by thoracotomy.

As described in more detail herein, in various embodiments of thedevices, methods and systems of the present invention, the pericardialportal of the present invention may be used for deployment of a CorCap(or similar device) into the pericardial space. The CorCap may then bepositioned using thorascopic tools, thereby eliminating the need forthoracotomy in these high risk patients.

Emplacement of a Left Atrial Portal

FIG. 1 illustrates the surface anatomy of a person with the location ofthe cardioscopic port. A relatively small (e.g., 2-3 cm) incision in themidline below (caudad to) the xyphoid allows access to the abdomenwithin the peritoneum or to the pericardial sac outside the peritoneum.

As illustrated in the figures, the cardioscopic (e.g., atrial) portal,or pericardial portal, may be positioned through the peritoneum andthrough the central tendon of the diaphragm. However, as is known bythose of skill in the art, other routes may be used provide access tothe pericardial sac via a sub-xyphoid location. For example, in oneembodiment, a pericardial portal or atrial portal can be inserted intothe abdomen through a small (e.g., about 1-3 cm) incision in theabdominal wall just below the xyphoid, and positioned adjacent to thediaphragm. Next, a cutting tool at the distal end of the pericardialportal 2 may be used to make a defect (i.e., opening) in the diaphragm.

The pericardial portal and/or atrial portal may then be threaded thoughthe abdominal wall until the pericardium is identified. For example, thepericardium may be identified under direct vision behind the xyphoid andoutside the peritoneal cavity or visualized with endoscopic guidance andan incision made in the pericardial sac for positioning of the atrialportal or the pericardial portal. Access to the epicardial surface ofthe heart via this sub-xyphoid approach enables procedures on thesurface of the heart described herein.

In FIG. 1, a pericardial portal 2 is seen in the upper abdomen 4 but notin the thorax 6. A similar entry is performed for the atrial portal (notshown).

In FIG. 2, the pericardial portal 2 is pictured within the peritonealcavity. The pericardial portal 2 is shown traversing the abdomen andpenetrating the diaphragm in the central tendon 8, anterior to the leftlobe of the liver 10 and to the left (i.e., anatomically) of thefalciform ligament 12. The diaphragm 14 is depicted.

In certain embodiments, as where using a pericardial portal, proceduresmay be performed where the pericardial sac is not opened, but thesurgery or positioning of a therapeutic device or tool (e.g.,defibrillator pads) is done on the outer surface of the pericardium. Thepericardial portal may be positioned via a surgical defect in thecentral tendon of the diaphragm such that the pericardial space iselevated and the distal end of the pericardial portal can be positionedbehind the pericardial sac. The distal end of the pericardial portal maycreate a temporary space between the pericardium and adjacentmediastinal structures. This allows extra-pericardial surgicalprocedures to be performed.

Alternatively, a cutting tool that extends from the distal end of thepericardial portal or the left atrial portal can be used create anincision in the pericardial sac allow for the distal end of the portalto be inserted into the pericardial sac and positioned in thepericardial space so as to create a temporary space within thepericardium (i.e., the pericardial sac). Positioning of the distal endof the portal within the pericardial sac allows surgical procedures tobe performed directly on the epicardial surface (i.e., the surface ofthe heart).

Each of the stages of positioning an atrial portal, or a pericardialportal may utilize an endoscope positioned within the lumen of theportal. In this way, the posterior side of the heart and/or other organsor body tissues of interest can be directly visualized using a viewingdevice (e.g., camera) at the proximal end of the endoscope.

There are a variety of routes that may be used to access the organ ortissue of interest. In certain embodiments, access to the pericardium isvia an incision below the xyphoid process and an incision in thediaphragm. In other embodiments, access to the pericardium may beobtained by a transcervical pathway. For example, access to thepericardium and the intrapericardial space may be gained by an incisionabove the clavicles and the sternum, by creating a space in thepre-tracheal fascial plane anterior to the trachea and posterior to thegreat vessels and cardiac structures and between the pleural spaces.Alternatively, the pericardium may be accessed by creating a window inthe pericardium behind the great vessels and superior to the dome of theleft atrium. The devices, methods and systems of the present inventionallow access to the heart from the posterior side of the patient,without interference from other organs in the thoracic cavity or thespine.

FIG. 3 illustrates an embodiment of a view at the distal end of apericardial portal 2 or the distal end of an atrial portal. The view maybe provided via an endoscope that is positioned within the lumen of thepericardial portal and/or an atrial portal. The view is within thepericardial sac. The posterior pericardium 16 is seen behind theposterior left atrium 18. The coronary sinus 20 is seen close to the endof the pericardial portal 2. The right 22 and left 24 inferior pulmonaryveins are illustrated. The anatomical structures are seen while theheart is beating and supporting normal circulation.

FIG. 4 illustrates a similar view of the pericardial anatomy as seen inFIG. 3. The entry location 26 for placement of a left atrial portal isidentified. The entry location (i.e., the position on the heart forinsertion of the left atrial portal through the atrial wall) may differdepending upon the type of procedure being performed. For example, theleft atrial portal may be positioned closer to the left inferiorpulmonary vein 24 for aortic valve procedures but closer to the rightinferior pulmonary vein 22 for mitral valve procedures.

FIG. 5 illustrates an embodiment of a purse string suture 28 that hasbeen placed around the left atrial portal position 26. The suture 28 canbe placed with endoscopic needle driver and other endoscopic suturinginstrumentation. Cotton pledgets 30,32 may be used to improve the sealfor the atrial portal in the left atrium, as well as to prevent traumato the atrial tissue. Although 2 pledgets are shown, the number ofpledgets may be varied as required by the size of the portal. Forexample, in some cases no pledgets are required, whereas in other casesmore than 2 pledgetts are required. Also, other types of supportelements may be used. The suture passes through one pledget 30. Thesuture is threaded inside the left atrial wall between 30 and 34 andbetween 30 and 36. The suture is seen on the atrial surface at 34, 36.The suture is then threaded inside the left atrial wall between 34 and32 and between 36 and 32, and then both ends of the suture are passedthrough another pledget 32 directly opposite the first pledget withrespect to the entry location 26 on the surface of the left atrium 18.When the suture is tightened, the pledgets can approximate and close thepurse string around the left atrial portal location 26 so as to providehemostasis and secure the left atrial portal to the left atrial surface18.

FIG. 6 illustrates a left atrial portal 38 passing through the outersurface 18 of the left atrium and secured by the purse string suture 30,32, 34, 36. As illustrated in FIG. 6, the proximal end of the leftatrial portal 38 may exit out of the abdomen of the patient.

Also depicted in FIG. 6 is cardioscopic tourniquet 40 that can be usedto secure the suture 28 around the left atrial portal 38. In anembodiment, the tourniquet may be a Rommel tourniquet. The cardioscopicRommel tourniquet should be sturdy enough to provide sufficientresistance to close the purse string as the suture 28 is tightened.Also, the tourniquet must also be of sufficient length for the proximalend of the tourniquet to be manipulated by the physician. In oneembodiment, the cardioscopic Rommel tourniquet 40 may be made oflatex-free plastic and is about from 10 to 30, 12 to 28, 14 to 26, 16 to24, or 18 to 22, or about 20 inches in length and has an internaldiameter of 1.0 to 3.0, or 1.5 to 1.8, or about 2.0 to 2.5 mm.

FIG. 7 illustrates an embodiment of a suture capture device 47 that maybe used with a left atrial portal of the present invention. The suturecapture device 47 may be passed through the cardioscopic Rommeltourniquet 40 (FIG. 7A) to capture the suture 28. The suture capturedevice may then be used to pull the suture into the distal end thetourniquet (FIG. 7B), through the tourniquet (FIG. 7C), and out theproximal opening of the tourniquet (FIG. 7D) where tension can beapplied to the suture 28 to secure the purse string 30,32,34,36 againstthe cardioscopic Rommel tourniquet 40.

FIG. 8A illustrates a pericardial portal 2 with the cardioscopic Rommeltourniquet 40, a left atrial portal 38, and an endoscope 44 emergingfrom the distal opening of the pericardial portal. FIG. 8A illustratesan embodiment where the tourniquet 40 is being used by a physician tosecure the purse string 28 around the left atrial portal. Also, shown inFIG. 8A is an endoscopic camera 44 attached to a video head 46 outsidethe proximal opening of the pericardial portal 2.

In some cases, where the pericardial portal 2 may not have an adequateopening to accommodate all the instruments required, a different accessfor placement may be used. This embodiment is depicted in FIGS. 8B-8D.

Thus, FIG. 8B demonstrates the pericardial portal 2 with a cardioscopicRommel tourniquet 40, and an endoscope 44 emerging from the distal (andproximal) openings of the pericardial portal. In this embodiment, aseparate guide wire 54 may be placed outside of the pericardial portal 2and into the pericardial space. The guide wire may then be inserted intothe entry location selected for insertion of the left atrial portal intothe left atrium (shown in FIG. 8C as centered within the purse stringsuture 30,32,34,36). The guide wire 54 can be placed through the sameaccess as the cardioscopic portal 2 or through a secondary access usingan introducer needle positioned outside the pericardial portal and intothe left atrium under endoscopic visualization of the endoscope withinthe pericardial portal.

FIG. 8C shows the left atrial portal 38 with a dilating introducer 56positioned at the distal end of the left atrial portal. The dilatingintroducer 56 can be used to increase the opening in the atrial wall asthe left atrial portal is inserted into the entry location bymanipulating the proximal end 57 of the introducer. As shown in FIG. 8C,the left atrial portal can be advanced along the guide wire 54 into thepericardial space and until the distal end of the left atrial portal isin adjacent to the entry location. Next the left atrial portal can bethreaded over the guide wire and inserted into the left atrial wall asdescribed in more detail in FIG. 9. Final placement of the left atrialportal 38 when external to the pericardial portal 2, is shown in FIG.8D.

FIG. 9 demonstrates placement of a left atrial portal in the left atrialwall. In FIG. 9A, the purse string has been positioned and the pledgets30,32 are seen on the epicardial surface of the atrial wall 48. A hollowbore needle 50 can be placed in the middle of the purse string (i.e., atthe identified entry location 26 for the left atrial portal) and intothe left atrium 52. As shown in FIG. 9B, a wire with a flexible tip 54may be passed through the distal end of the needle 50 and positionedinside the left atrium 52. As shown in FIG. 9C, the needle may then bepulled proximally out of the atrial wall 48 while leaving the wire inthe atrium. In one embodiment, and as depicted in FIG. 9C, the guidewire inserted into the left atrium passes from outside the abdomenthrough the pericardial portal (not shown) and into the left atrium 52.FIG. 9D demonstrates the position of the left atrial portal 38 withinthe left atrium 52 over the guide wire 54. As shown in FIG. 9D, the leftatrial portal 38 may be advanced over the guide wire 54 and positionedadjacent to the entry location. At this point, a removable dilatingintroducer 56 within the left atrial portal central lumen can bepositioned over the wire 54 so as to engage the opening 28 in the leftatrial wall 48. By pushing the left atrial portal distally, the dilatingintroducer may be inserted into the left atrial wall, thereby expandingthe opening.

At this point, the left atrial portal may be secured in the left atrialwall. FIG. 9D demonstrates the use of a distal cap 58 to secure the leftatrial portal 38 in the left atrial wall. The distal cap may be made offirm silastic or other surgically acceptable material. In certainembodiments, the cap may be coated with heparin. In certain embodiments,the distal cap may be formed with a central opening and an externaldiameter that is widens from proximal to distal. In this way the mostdistal part of the cap is wider than the proximal end of the cap. In anembodiment, the cap narrows at the portion of the cap that is locatedwithin the left atrial wall 48. The narrow neck helps secure the cap andthe portal to the left atrial surface.

In certain embodiments, the cap may have elements on the proximal end ofthe cap to secure the cap in the atrial wall so as to prevent the leftatrial portal from be inserted any further into the left atrium, so asto limit the amount of device which can be placed inside the leftatrium. For example, in some embodiments, the cap may comprise at leasttwo flat elements (e.g., wings) 59 a, 59 b that extend from the centraldiameter of the cap. The wings may be of the same material as the restof the cap or may be made of a different material. The wings may bepositioned at about the narrow neck of the cap. The wings may alsoprovide additional security as the pledgets 30, 32 can be positionedexternal to the wings of the cap to secure the wings to the left atrialwall as the purse string is tightened. In an embodiment, and as shown inFIG. 9, the wings may be inserted underneath the pledgets 30,32 suchthat tightening the sutures can be used to further secure the portalagainst the atrial wall.

FIG. 9, panels E-H, shows an embodiment where the left atrial portal,dilating introducer, and needle are inserted as one unit. In FIG. 9E,the purse string has been positioned and the pledgets 30,32 are seen onthe epicardial surface of the left atrium 48. The left atrial portal 38,dilating introducer 56, and needle 50 are positioned in the middle ofthe purse string on the left atrium 52. FIG. 9F shows the needle 50advanced through the wall 48, and into the left atrium 52. FIG. 9G showsan embodiment where a wire with a flexible tip 54 has been passedthrough the needle 50, and is positioned inside the left atrium 52. Theleft atrial portal unit 38, dilating introducer 56, and needle 50 (whichin some cases may be partially withdrawn) can then be advanced as oneunit through the left atrial wall 48. FIG. 9H, shows the left atrialportal 38 threaded over the guide wire 54 and into within the leftatrium 52, but with the needle withdrawn back into the left atrialportal and removed via by the operator by pulling the needle proximallyout of the left atrial portal.

FIGS. 10A and 10B illustrate other embodiments of the left atrialportal. FIG. 10A illustrates the distal end of a left atrial portalwithout the atrial wall cap. As shown in FIG. 10A, this embodiment maybe secured in the atrial wall 48 by tightening the purse string sutureand pledgets 30, 32 once the distal open end is within the left atrium52.

FIG. 10B is an embodiment of a left atrial portal that comprises anexpandable cap 62 at the distal end of the left atrial portal. In anembodiment, the expandable cap may be used to secure the left atrialportal to the left atrial wall 48. In an embodiment, the expandable cap62 has a distal portion 63 which, once inside the left atrium 52, can beexpanded so as to increase the diameter of the cap and securepositioning of the cap so that the cap (and thus, the left atrialportal) cannot be pulled out of the atrium. The expandable cap 62 alsohas a more proximal portion 65 which is positioned external to the leftatrium such that when this portion of the cap is expanded, the cap (andthus, the left atrial portal) cannot be further inserted into theatrium. In an embodiment, the cap may be heparin coated. The cap may beexpanded with a gas (e.g., air) or a fluid (e.g., saline) that isinjected through a lumen opening at the proximal end of the left atrialportal.

The proximal end of the left atrial portal may be fashioned to allowmanipulation and access to various tools that are to be inserted intothe left atrium. Also, the proximal end of the left atrial portal may befashioned so as to facilitate insertion of the left atrial portal intothe into the atrial wall by the physician, as e.g., to facilitate use ofan ultrasound probe or other imaging equipment, or to facilitate use ofneedles, guide wires, the dilating introducer and/or the expandabledistal cap as described herein.

One embodiment of a proximal end of an atrial portal and/or acardioscopic portal of the present invention is shown in FIG. 10C. Theremay be an addition to the proximal end to allow the passage of devicesover the atrial portal, such as a larger portal to be inserted over theatrial portal 38. For example, a portal may be threaded over an atrialportal and used to place a suture in the atrial wall. In an embodiment,such an over-lying portal is a pericardial portal 2.

In certain embodiments, the proximal end of the atrial portal or apericardial portal of the present invention may comprise a one way valve66. Additionally or alternatively, the proximal end of the atrial portalor pericardial portal of the present invention may also have threads 68for the attachment of extensions and adaptors 70. Such proximal adaptorsand/or end pieces may have a cap 72 which can attach to threads 68 onthe left atrial portal or the pericardial portal of the presentinvention. Also, in certain embodiments, such proximal adaptors maycomprise one or more one-way valves 66. Where the proximal adaptorprovides an extension to the portal, if may further comprise an openproximal end 76. Also, in certain embodiments, the proximal adpator/endpiece may comprise an arm 78 for the attachment of a valve (e.g., athree-way valve or other valves) 60 for infusion of fluids.

FIG. 10E, depicts an alternate embodiment of the proximal end of a leftatrial portal or pericardial portal of the present invention. Thus, asillustrated in FIG. 10E, the left atrial portal 38 or a pericardialportal may, in certain embodiments, comprise a nonremovable port 72having a one way valve 66 and a stopcock assembly 60. This configurationmay be used to decrease the chance for air to enter into the left atriumas could occur with a detachable threaded proximal port (e.g., if port72 were detachable). FIG. 10F shows an embodiment of a proximal port 72in a head on view. The one-way valve opening 66 may be sized to acceptthe dilator introducer 56 used for introduction of the distal end of theleft atrial portal into the left atrium.

FIGS. 10G and 10H depict a proximal port 72 with a diameter that expandstowards the proximal direction. As shown in FIG. 10G, the port maycomprise multiple valves (e.g., one-way) that provide access to a leftatrial portal or a pericardial portal of the present invention. The portshown in FIG. 10G (top view) and 10H (head-on view) may comprisemultiple one-way valves 66. Although the port is depicted as beingtriangular in shape, other shapes may be used. The left atrial portal 38or pericardial portal can be sized as needed to allow more than onecatheter or other instrument to be passed into the left atrium. Anexample is a mapping and ablation catheter.

FIG. 11 is a diagram of the inside of the left atrium 52 as accessed bya left atrial portal 38 of the present invention showing the rightsuperior pulmonary vein orifice 82, the right inferior pulmonary veinorifice 84, the left superior pulmonary vein orifice 86, the leftinferior pulmonary vein orifice 88, and the orifice to the left atrialappendage 90. The posterior annulus of the mitral valve 92 is alsodepicted. It can be seen that the distal end of the left atrial portal38 enters the left atrium 52 such that the internal portion of thedistal cap 58 is within the internal wall of the left atrium surroundedby the purse string suture 28.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access to insert surgical toolsand/or therapeutic devices in the left atrium. FIG. 12 illustrates aleft atrial portal 38 and distal cap 58 positioned in the left atrialwall 48 such that the left atrial portal provides access to the leftatrium 52. In an embodiment, and as illustrated in FIG. 12, the leftatrial portal allows for a catheter (ablation, sensing electrode,angiography, or pressure-monitoring) 94 to be inserted directly into theleft atrium 52 from outside the abdomen via the central lumen of theleft atrial portal 38. The catheter may, for example, be an ablationcatheter that can be directed into the right superior pulmonary veinorifice 82 or the right inferior pulmonary vein orifice 84 to treatarrhythmias originating in these locations. Other embodiments mayinclude placing electrodes or pressure monitoring catheters atanatomical locations within the left atrium.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access for treatment of valvesin the left atrium or parts of the heart that are accessible via theleft atrium. FIG. 13 illustrates an embodiment of a method of using aleft atrial portal of the present invention for repairing valves in theheart. Thus, as illustrated in FIG. 13, the left atrial portal 38 anddistal cap 58 are positioned in the left atrial wall 48 so as to provideaccess, via the distal opening of the left atrial portal 38 to theinside of the left atrium 52. As shown in FIG. 13, a catheter with ahollow central lumen 96 may be threaded into the left atrium via thecentral lumen of the left atrial portal 38. The catheter may then bethreaded by the physician manipulating the catheter at the proximal endof the left atrial portal to the valve requiring therapy. For example,in an embodiment, and as depicted in FIG. 13, the catheter may bethreaded through the mitral valve 98, and through the left ventricle100, out the aortic valve 102, and into the ascending aorta 104. Next,and as shown in FIG. 13, a guide wire having a flexible tip 54 may bepassed through the catheter 96 into the ascending aorta, through theaortic arch 106 and down the descending thoracic aorta 108. The catheter96 can then be removed leaving the wire 54 in place. This wire providesa platform for the positioning of devices (stents, valves) in the aorticvalve 102 or the aorta 104,106,108.

In an embodiment, echocardiography or ultrasound can be used to confirmpositioning of the guide wire and other tools in the heart.Alternatively, in some embodiments, an endocardiograpic catheterpositioned in the lumen of the left atrial portal or alternativelyadvanced into the left atrium may be used.

In certain embodiments, and as illustrated in FIG. 14, the catheter 96may be removed to allow for emplacing a dilator catheter 110 andassociated dilating balloon 112 in the aorta using a left atrial portalof the present invention. Thus, as illustrated in FIG. 14, the catheter96 (not shown) may be pulled back into the left atrial portal. At thispoint, a dilator catheter and balloon may be threaded along the guidewire 54 and positioned in the aortic valve. The balloon 112 may beexpanded (e.g., with saline) to an appropriate pressure to compress thediseased aortic valve to the wall of the aorta, thus increasing theinternal diameter of the aortic valve and making it more acceptable forstented valve deployment. In certain embodiments, and as depicted inFIG. 14, the device used for valve repair may include a debris capturedevice 114 to capture any debris which may be broken free from thevessel or the valve during the procedure. In an embodiment, the devicefor capturing such debris may be shaped like a parachute or umbrella.The debris capture device 114 may be positioned on the guide wire 54downstream (i.e., in relation to blood flow) of the balloon 112 tocapture loosened debris so as to decrease the risk of embolic event suchas stroke. The capture device 114 may be included as part of the balloondilator 110 or may be a separate, independent device. The deployment ofthe capture device may be performed by advancing the capture device 114in an unexpanded configuration out the distal end of the catheter 110.Once released from the catheter 110, the capture device can be expanded(opened) by the intrinsic blood flow in the aorta. The capture device114 may include attachment cords 116. Such attachment cords 116 canprovide support, maintain the device in an expanded configurationdespite variations in blood flow, and provide a mechanism for removal ofthe capture device at completion of the procedure. For example, once theprocedure for repair of the valve is completed, the attachment cords 116can be withdrawn, collapsing the capture device 114 around the debris,and then the collapsed capture device (and captured debris) can bewithdrawn through the left atrial portal 38. Once the aortic valve isadequately dilated, the balloon is withdrawn leaving the guide wire 54in position.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access for emplacement ofstented valves in the left atrium or parts of the heart that areaccessible via the left atrium. FIG. 15 demonstrates the stented aorticvalve prosthesis 118, 119 on a sheath 120 with a tapered distal end thathas been advanced and over the guide wire 54 and positioned in the aorta104. In an embodiment, the sheath may have an expandable portion onwhich the stent 118 and valve prosthesis 119 is mounted. When expanded,the sheath can secure the prosthesis into the appropriate position atthe aortic valve 102. Once the stent 118 and prosthesis 119 are deployedsuch that it is securely positioned within the wall of the aorta, theintroducer 120 can be removed leaving the guide wire 54 in position.

FIG. 16 demonstrates an aortic stented valve prosthesis 118, 119 inappropriate positioned at the location of the aortic valve. At thispoint, the guide wire 54 and the left atrial portal 38 may be removedand the purse string suture (not shown) can be tightened to close theopening in the left atrial wall 48.

The devices, methods and systems of the present invention may be used totreat other valves that are accessible via the left atrium. FIG. 17depicts emplacement of a stented mitral valve prosthesis at the mitralvalve 98 using the devices, methods and systems of the presentinvention. The stented mitral valve prosthesis 121, 122 may be deployedin the similar manner as described for the aortic valve, as for exampleusing an expandable introducer 123 to deploy the stent 122 andprosthesis 121 into the appropriate position in the valve 98. Again, theguide wire 54 may be used as a platform to position the introducer 123and the stent and prosthesis 121, 122. In this embodiment, the guidewire is threaded into the left ventricle 100. Echocardiography can beused to confirm position of the aortic and the mitral valve prosthesisand to confirm appropriate location and function after deployment.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access for reduction of theposterior annulus of the mitral valve for patients with mitralregurgitation. To enable reduction of the posterior annulus of themitral valve, suture material can be positioned into the posteriorannulus to provide an anchor for tissue approximation. FIG. 18Ademonstrates one embodiment of one such suture anchor device. FIG. 18Ais an example of a “twosided” barbed needle 124 with attached suture126. The barbed suture can be deployed into the annulus of the posteriormitral valve to secure the suture in the annulus of the posterior mitralvalve for annular approximation. When the barbed needle is inserted,counter-traction (i.e, by pulling distally) can be used to engage thebarbs in the mitral valve annulus tissue such that the barbed needle issecurely positioned in the annulus of the posterior mitral valve. Suchbarbed needles can be inserted easily using the devices, methods andsystems of the present invention and, by securing two or more sutures,can provide sufficient capture of the mitral valve annulus to allowreduction of the posterior mitral valve annulus.

FIGS. 18B and 18C shows a barbed needle 124 and associated introducerneedle 128 that may be used to insert the needle in the proper location.The barbed needle 124, when within the introducer needle 128 does nothave the barbs exposed (FIG. 18B). When the barbed needle 124 isadvanced, as in FIG. 18C, the barbs are exposed and can be securelyinserted into (i.e., capture) adjacent tissue, preventing removal andretraction.

In certain embodiments, the barbed needle also comprises a sheath,positioned over the suture, and that abuts the base (i.e., proximal end)of the needle. Such a sheath may be used to push the needle out thedistal end of the introducer needle. FIG. 19, panels A and B,demonstrates how the barbed needle 124 is advanced out the end of theintroducer needle 128 using a sheath 130 that is threaded over thesuture 126. As the sheath 130 is advanced, it is able to push againstthe base of the barbed needle 124. The sheath 130 has a central lumenwhich is large enough to cover the suture 126, but which is not largerthan the barbed needle 124. This allows the physician manipulating theproximal end of the sheath to introduce the barbed needle into thetissue as the sheath is advanced distally through the introducer needle.

FIG. 20 demonstrates one example of the use of the devices, methods andsystems of the present invention for positioning an introducer needle128 (and associated barbed needle, not shown) into the posterior mitralvalve annulus 98. As shown in FIG. 20, the introducer needle 128 may becontained within the central lumen of a steerable catheter or sheath132. The steerable sheath 132 may be passed through the left atrialportal 38 into the left atrium 52 and towards the mitral valve 98. Oncethe distal end of the steerable sheath is positioned close to the mitralvalve, the introducer needle 128 can be advanced out the distal end ofthe steerable sheath 132.

FIG. 21 depicts placement of the introducer needle 128 in the posteriorannulus tissue of the mitral valve 98. As shown in FIG. 21, thesteerable sheath 132 can be manipulated so as to emerge from the leftatrial portal 38, and is threaded through the left atrium 52, and to themitral valve where the introducer needle 128 is inserted into theannulus of the mitral valve using echocardiographic guidance. Once theintroducer needle 128 is in position, the barbed needle 124 may beadvanced into the annular tissue where it is secured.

Reduction of the posterior mitral valve annulus may generally employ twoor more such barbed needles that are implanted in the poterior mitralvalve annulus. FIG. 22 demonstrates two barbed needles 124 in theposterior annular tissue of the mitral valve 98. The needles aregenerally positioned at a distance from each other which may range fromabout 1 to 5 cm, depending upon the extent of reduction required. Asillustrated in FIG. 22, the suture 126 of each barbed needle 124 mayexit the left atrium 52 via the left atrial portal 38. The location ofthe barbed needles 124 in the annulus is selected to cause the posteriorannulus to be reduced when the sutures are tightened and the needles arebrought into approximation. As the needles are approximated, the annuluswill be plicated, or reduced. Using the devices, methods and systems ofthe present invention, reduction of the mitral valve annulus may beevaluated, in real-time (i.e., on the beating heart), byechocardiography to determine reduction in mitral valve regurgitation asthe sutures are tightened.

FIG. 23 depicts the reduction of the annulus as two barbed needles 124are drawn closer to each other. A clasp 134 may be advanced over thesuture to the point that the clasp approximates the barbed needles andholds them in the correct position. In an embodiment, advancement of theclasp 134 over the suture 126 may be done using a clasp advancingcatheter (not shown) with an open central lumen that can be threadedover the suture (i.e., one suture per barbed needle) to push the claspdistally. The clasp may be advanced as the mitral valve regurgitation isinterrogated. Once the appropriate reduction of the annulus is achievedand the mitral regurgitation is eliminated, the clasp advancing cathetermay be removed, leaving the clasp 134 remaining in position with theappropriate tension on the sutures 126.

FIG. 24 depicts another embodiment of posterior mitral valve reduction.Using a steerable sheath 132 positioned through the left atrial portal38, a radiofrequency needle 135 may be positioned at selected locationsin the mitral valve annulus. Ablation of the tissue 136 to create a scarcan then lead to contraction of the tissue around the mitral valve. Whena series of ablations 136 within the posterior mitral valve annulus arecreated, the contraction which occurs can reduce the annulus and therebyreduce mitral regurgitation. The radiofrequency needle 135 generatesthermal heat within the cardiac tissue.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access to the heart to allowfor implantation of intracardiac assist devices (ICADs). FIG. 25demonstrates an embodiment of an intracardiac assist device 140 for abridge to transplantation. When positioned in the left ventricle, theICAD is used to encourage blood flow from the left ventricle 100 out theaorta 104. As depicted in FIG. 25, the ICAD 140 may be secured, in someembodiments, by a stent positioned at the ejection end 138 of the ICAD.The stent 138 may be part of the ICAD 140 or, in alternate embodiments,may be a separate device. The ICAD generally is configured with inflowopenings 142, where blood may be drawn into the ICAD. The blood may thenbe ejected with a pump 144 contained within the ICAD 140. In alternateembodiments, the internal ICAD pump may be a centrifugal head pump, adiaphragm pump, or an impellar type pump.

Similar to implantation of other devices, and as depicted in FIG. 25,the ICAD may be inserted over a guide wire 54 (partially withdrawn)which is positioned using a left atrial portal 38. Thus, as shown inFIG. 25, the guide wire may be threaded through the left atrium 52, themitral valve 98, the left ventricle 100, and out the aorta 104. With theguide wire 54 in place, the ICAD device may then be inserted and, oncein appropriate position, the distal stent portion deployed to secure thedevice. As known by those in the art, other embodiments may includeother mechanisms to secure the ICAD to the endocardial surface andprevent migration.

Once the ICAD is secured in place, energy may supplied by a cable 146which exits through the mitral valve 98 and left atrium 52 to a powersource (e.g., generator) placed subcutaneously in the abdominal wall. Ina similar manner, temporary assist devices which currently exist on themarket, i.e. NOVACOR® (World Heart, Salt Lake City, Utah) or HEARTMATE®(Thoratec, Pleasanton, Calif.), may be inserted. A venous drainagecannula can be inserted through the left atrium 52 and into the leftventricle 100 via a left atrial incision similar to the one for the leftatrial portal. This cannula can be connected to the temporary assistdevice in the abdominal wall on the inferior side of the diaphragm. Thearterial inflow limb (i.e., the part of the pump used to return theblood to the aorta from the left atrium or left ventricle) can be awoven graft tunneled to the subclavian artery on the left or right or tothe abdominal aorta. In a similar manner, an IMPELLA® device (Abiomed,Danvers, Mass.) can be inserted via the left atrial portal into aposition in the left ventricle so that the ejected blood passes into theaorta.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access to the heart to allowfor implantation of electrical leads for pacing the heart. FIG. 26,panels A-C, depicts an embodiment of a cardioscopic pacing lead that maybe implanted within the heart or on the outer surface of the heart usingan atrial portal, or a pericardioscopic portal of the present invention.Thus, as shown in FIG. 26A, the cardioscopic pacing lead 225 may have aproximal end having the bipolar or unipolar lead attachment 226. Incertain embodiments, and as depicted in FIG. 26A, the distal end mayhave an active fixation mechanism 227. The fixation mechanism may, incertain embodiments include an extendable/retractable screw 228 and anexternal head 229. The shape of the head may be varied as required; FIG.26B depict a head that is of a hexagon shape (head-on view) but othershapes may be used. For example, in alternate embodiments, the head maybe rectangular, square, or another polygonal shape to facilitate use ofa socket type wrench being used to rotate the head and screw the coilinto the epicardial tissue.

FIG. 26C shows an embodiment of a fixation unit 230 for the lead (notshown in unit). The distal end 231 of the fixation unit may have arecessed cavity 232 for insertion of the head (e.g., shown as hexagonshape) which fits over the active fixation mechanism 227 and onto theexternal head 229. In certain embodiments, the extendable/retractablescrew 228 (FIG. 26A) can be either advanced or withdrawn by use of ahandle 233 which may be attached by a cable mechanism or gear mechanism234 to the distal end 231 of the fixation unit, and which may have theability to rotate. This can allow for either extension or retraction ofthe extendable/retractable screw 228.

As described in detail herein, the devices, methods and systems of thepresent invention can provide for direct access to the heart to allowfor implantation of left atrial pressure sensors. FIG. 27, panels A-C,depict an embodiment of a left atrial pressure sensor, and deployment ofsuch a sensor in the left atrium in accordance with an embodiment of thepresent invention. FIG. 27A shows the left atrial pressure sensor 235having a proximal end 237 and a distal end 236, and which may beemplaced using a left atrial portal of the present invention. The distalend 236 may be made of silicone or similar material, and be sized tohave a circumference that is larger the inside diameter of the leftatrial portal 38, but which is flexible enough to be inserted throughthe distal opening of the left atrial portal 38 and deployed into theleft atrium 52 (FIG. 27B). The depiction in FIG. 27B shows the leftatrial portal 38 deployed in the atrial wall and having the pressuresensor 235 contained within the lumen of the left atrial portal andemerging from the distal end of the left atrial portal into the atrium52. At this point, the distal end 236 of the pressure sensor 235 maythen be pulled proximally against the left atrial wall 48. Once thepressure sensor has been positioned to abut the left atrial wall 48, theleft atrial portal 38 can be removed (i.e., pulled out of the patient),and the suture (not shown) and pledgets 30,32 tightened to secure thepressure sensor in position. FIG. 27C shows a left atrial pressuresensor 235 in the final deployed position.

As noted in the various embodiments described herein, in certainembodiments, the devices, methods and systems of the present inventionprovide access to the pericardial space. FIG. 8 depicts an embodiment ofa portion of a pericardial portal of the present invention. FIG. 28,panels A-C, depicts an alternate embodiment of a pericardial portal 2 ofthe present invention. Thus, as shown in FIG. 28, in some embodiments,the distal end 239 of the pericardial portal 2 may be tapered to preventtrauma to the cardiac structures and to allow the distal end to be flushagainst the myocardium. In certain embodiments, the pericardial portalmay include a tube to provide suction 240. Also in certain embodiments,the pericardial portal may include an infusion port 241 incorporatedinto the wall of the pericardial portal, and which allows for suctioningof the pericardial space and infusion of fluid or contrast. Near thedistal end of the pericardial portal there may be access ports 242 oneither side of the portal to allow the passage of instruments,catheters, or scopes out of the portal. These access ports 242 may beoutlined with radiographic markers 243 to allow visualization underfluoroscopy. The proximal end may, in certain embodiments, have asecuring mechanism 244 to prevent slippage.

FIG. 29 shows the pericardial portal 2 with ablation catheters 245 onthe epicardial surface of the left atrium 52 and left ventricle 100.Shown is the right atrium 53, right ventricle 101, the pericardialcannula 2 inserted via an incision 246 into the pericardial space. Thedistal end of the catheter 249 may be manipulated by the physician.

Methods of Making Left Atrial Portals

In other embodiments, the present invention may comprise methods ofmaking the devices either singly, or in combination with othertherapeutic devices as kits or systems. For example, in certainembodiments, the method may comprise manufacturing an atrial portal,and/or a pericardioscopic portal of the present invention. Also, themethod may comprise manufacturing inner cannulas, catheters and/orsheaths comprising a tool or tools used for the procedures describedherein.

The body of the left atrial portal and/or the pericardioscopic portalmay be made of a rigid material so as to provide support formanipulation of the distal end of the portal at the body site ofinterest. For example, the atrial portal and/or the pericardioscopicportal may be fashioned from a plastic that while soft enough to preventtrauma to any tissues or organs encountered by the portal, will allowfor certain organs (e.g., the heart) to be lifted from their normalpositions and manipulated as required. For example, metals such asstainless steel, spring steel, nickel titanium alloys, other alloys, oraluminum may be used. Or, the portal(s) may be made of plastic. Forexample, a resilient plastic such as vinyl, nylon, polypropylene,polyethylene, ionomer, polyurethane, or polyethylene tetraphthalate(PET) may be used. Again, one of ordinary skill in the art having thebenefit of this disclosure would appreciate that other materials,including those that are well-known to one in the art, may be applied toconfigure the portals described herein.

Also, in certain embodiments, the atrial portal and/or the pericardialportal may comprise reinforcing elements. The reinforcing elements canallow the portal to bend as it is maneuvered around and to body sites ofinterest without allowing the portal to collapse. Such reinforcingelements may comprise strands of metal or sturdy plastic that can bemolded into the portal body using methods known in the art.

The distal end of the atrial portal and/or the pericardial portal may besubstantially planar. Or, the distal end may be formed so as to have acurvilinear shape. Generally, the atrial portal may comprise a distalend that is substantially flush with the cross-sectional diameter of theportal so that the distal end of the atrial portal is substantiallysquare (i.e., perpendicular) to the long axis of the atrial portal asviewed from the side (e.g., as shown in FIG. 10A for the atrial portaland FIG. 2 for the pericardial portal). In an embodiment, thepericardial portal may have a curvilinear distal portion such that thedistal opening is not parallel to the proximal opening, but includestapering along at least a part of the circumference (e.g., as shown inFIG. 28). Also, in certain embodiments, the pericardial portal maycomprise a curvilinear or hood-shaped formation at the distal end, whichcan provided an arched shape to the distal end of the pericardialportal. In this way, the pericardial portal may facilitate access to theheart where a straight cannula would not be able to abut the surface ofthe heart. Or, the pericardial portal may comprise a substantiallystraight cylindrical shape.

Also, in certain embodiments, the atrial portal and/or the pericardialportal may be designed to have one or more narrowed openings at certainparts of the distal opening to facilitate positioning of tools in thedistal opening. Also, the distal end of the atrial portal and/or thepericardial portal may have an expanded opening, such that thecircumference of the distal opening is greater than the circumference ofthe proximal opening of the portal.

The distal end of the atrial portal and/or the pericardial portal may bemade of a rigid material so as to provide support for manipulation ofthe distal end at the body site of interest. For example, the distal endof the atrial portal and/or the pericardial portal may be fashioned froma plastic that while soft enough to prevent trauma to any tissues ororgans encountered by the cannula, will allow for certain organs (e.g.,the heart) to be lifted from their normal positions and manipulated asrequired. For example, in certain embodiments, Silastic or plastic withwire or Nitinol reinforcement may be used. Or, the distal end of theatrial portal and/or the pericardial portal may comprise a hard plastic(e.g., polypropylene, polyethylene) and have a rubber or foam cushionmaterial on its distal end.

The atrial portal and/or pericardial portal may comprise a distal endhaving a malleable material that is suitable to contact the tissue. Forexample, the pericardial portal may comprise a soft lip, made of rubberor foam at its distal end.

As described herein, in certain embodiments, the atrial portal has a capat the distal end. The cap may be made of materials such as a softplastic, foam, rubber, polyurethane foam, or polystyrene foam. Incertain embodiments, at least part of the cap may be expandable and/orinflatable so as to have an portion that can be expanded outwards of thecentral longitudinal axis of the portal.

Also, many of the tools used with either the pericardial portal and/orthe atrial portal may comprise an inflatable member. For example, aninflatable member may be positioned on the distal end of the portal andmay be inflated to provide an extended diameter when the portal isthreaded between various organs or tissue sites. Or, an internalcatheter having an inflatable member may be used to expand a vesselprior to implantation of a stent and/or valve prosthesis. The balloonmay be made of an expandable plastic or cloth such as silastic or softplastic or thin Gortex.

In an embodiment, the atrial portal and/or pericardial portal arecylindrical in shape. Or, the cross-sectional shape of the portals maybe other shapes, such as oval, rectangular, polygonal (e.g., hexagonal,octagonal) and the like.

The atrial portal and/or pericardial portal may be constructed so as tobe sufficiently rigid such that the portal does not bend substantiallywhen inserted into other portals or when being tunneled to the body siteof interest. Also, the portal(s) may comprise a material that iscompatible with the other parts of the system.

Or, the atrial portal and/or pericardial portal may be fashioned to havea distal portion that can be articulated such that the distal openingcan be rotated from having a configuration that is substantiallystraight such that the distal opening is substantially parallel with theproximal opening, to having a distal opening that is not parallel to theproximal opening of the portal. The ability to articulate may beeffected by forming the end of the portal with overlapping concentricrings that can be separated from each other on one side of the portaland squeezed together on the other side of the portal. In an embodiment,the articulation may be effected proximally using a connector that canshorten one side of the portal while allowing the other side tolengthen. Or, articulation may be effected distally by pushing on a partof the distal end of the portal so as to shorten one side of the portaland lengthen the other side.

In certain embodiments, the pericardial portal or atrial portal may befashioned to include a guide wire at its distal end. The guide wire maybe made of stainless steel or other metal. The guide wire may beinserted at or near the proximal end of the portal and may extendthrough the portal (e.g., via a central lumen, or a lumen in the wall ofthe portal) to emerge at the distal end.

Also, a suction and/or infusion lumen may be incorporated into theatrial portal and/or the pericardioscopic portal. In certainembodiments, the suction lumen is an individual channel within theportal or the portal wall. The suction lumen may end with an aperture orapertures at the distal end of the portal. Or, a plurality of suchsuction lumens in the portal wall (e.g., one or more suction lumenssurrounding, or at least partially encircling, the distal opening) maybe used.

As described above, the portals of the present invention may be sizedsuch that the atrial portal comprises a diameter less than the internaldiameter of the pericardial portal. For example, the pericardial portalmay comprise dimensions on the order of about 2 to 30 inches, or about 4to 20 inches, or about 6 to 12 inches, or about 8 inches in length.Also, in alternate embodiments, the pericardial portal may have an innerdiameter that ranges from about 0.15 to 3 inches, or from about 0.25 to2.5 inches, or from about 0.35 to about 1.2 inch, or from about 0.5 to 1inch. The atrial portal may be about the same length, but is generallysmaller in diameter, having an inner diameter that ranges from e.g.,from about 0.1 to 2.0 inches, or from about 0.2 to 1.5 inches, or fromabout 0.3 to about 1 inch, or from about 0.4 to 0.8 inches.

In yet other embodiments, the present invention comprises methods tomake device that may be used with the endoscopic portals of the presentinvention. Such devices may be fashioned as described herein. Or,devices substantially equivalent to such devices may be fashioned.

Thus, in yet other embodiments, the present invention comprises methodsto make a devices for suturing the entry location for an atrial portal(or a pressure sensor delivered by an atrial portal), or tools forperforming procedures on the left or right atrium or portions of theheart accessed by the left or right atrium such as, but not limited toablation elements, electrodes, valves, stents and the like. Also, otherembodiments of the present invention comprise methods for making innercatheters/cannulas having such tools attached to the distal end with orwithout the inclusion of an inflatable member and associated lumen.

Depending upon the specific application, the tools/accessory devicesthat are made for use with a portal of the present invention maycomprise a material that is flexible, such that the tool/device is ableto bend, or the tool may comprise a material that is substantiallyrigid. Thus, in alternate embodiments, the various tools/devices maycomprise a metal such as aluminum, stainless steel, spring steel, nickeltitanium alloys, or other alloys. Or, the tools/accessory device may bemade of plastic. For example, a resilient plastic such as vinyl, nylon,polypropylene, a polyethylene, ionomer, polyurethane, and polyethylenetetraphthalate (PET) may be used.

Each of the components used in the devices and systems (e.g., kits) ofthe present invention may comprise a material that may be sterilized byeither chemical treatment, high temperature, and/or high pressure,exposure to sterilizing gas, or a combination of sterilizationtreatments as is known in the art. Also, the components of the devicesand systems of the present invention may be disposable, or may beformulated to allow for cleaning, re-sterilization, and re-use.

All patents, publications and abstracts cited above are incorporatedherein by reference in their entirety. It should be understood that theforegoing relates only to certain embodiments of the present inventionand that numerous modifications or alterations may be made thereinwithout departing from the spirit and the scope of the present inventionas defined in the following claims.

1. A device for accessing an atrium of a heart in a subject so as toperform a surgical procedure upon the atrium, the device comprising anatrial portal having a configuration such that the distal end of theatrial portal can provide cardioscopic access the atrium while theproximal end of the atrial portal can extend to outside of the subject.2. The device of claim 1, wherein the cardioscopic access is via anincision in the diaphragm and via the pericardial space.
 3. The deviceof claim 1, wherein the atrium is the left atrium.
 4. The device ofclaim 1, further comprising a pericardial portal into which the atrialportal is inserted, the pericardial portal having a configuration suchthat the distal end of the atrial portal can access the atrium while theproximal end of the atrial portal can extend to outside of the subject.5. The device of claim 1, further comprising an imaging device toprovide an image of body structures present near the distal end of theatrial portal.
 6. The device of claim 1, further comprising a toolconfigured for emplacing sutures in the atrial wall to secure the atrialportal in the atrium wall.
 7. The device of claim 6, wherein the suturesare of a configuration so as to surround the atrial portal uponinsertion of the atrial portal in the atrium such that tightening thesutures around the atrial portal secures the atrial portal in theatrium.
 8. The device of claim 6, further comprising a tourniquetconfigured to tighten the sutures around the atrial portal.
 9. Thedevice of claim 1, wherein the atrial portal further comprises a needlewithin the lumen of the atrial portal, wherein the needle is configuredto puncture the atrium so as to provide an opening for insertion of theportal into the atrium.
 10. The device of claim 1, wherein the atrialportal further comprises a guide wire, wherein the guide wire isconfigured to provide a path for insertion of the atrial portal into theatrium by threading the atrial portal over the guide wire and into theatrium.
 11. The device of claim 1, wherein the distal end of the atrialportal comprises a dilating introducer, wherein the dilating introduceris configured so as to be inserted in an opening in the atrial wall soas to enlarge the opening of the atrial wall for insertion of the atrialportal into the atrium.
 12. The device of claim 1, wherein the distalend of the atrial portal comprises a cap configured to secure the distalend of the atrial portal in the atrial wall.
 13. The device of claim 12,wherein at least a portion of the cap can be expanded laterally awayfrom the central longitudinal axis of the atrial portal.
 14. The deviceof claim 1, further comprising at least one tool for performingprocedures on the atrium or a region of the heart accessible via theatrium.
 15. The device of claim 14, wherein the tool is configured to bethreaded over a guide wire that extends from the proximal end of theatrial portal to the distal end of the atrial portal.
 16. The device ofclaim 14, wherein the tool comprises at least one of an ablationelement, an electrode, a stent, a valve, an expandable member, a debriscapture device, or a barbed needle.
 17. A method to access the atrium ofa heart in a subject so as to perform surgical procedures upon theatrium, the method comprising: (a) inserting the distal end of an atrialportal into the pericardium of the subject; (b) manipulating theproximal end of the atrial portal to position the distal end of theatrial portal at the surface of the atrium; (c) determining an entrylocation for the atrial portal to be inserted into the atrium; (d)inserting the atrial portal into the atrium; and (e) securing theposition of the atrial portal in the atrium.
 18. The method of claim 17,further comprising inserting the atrial portal into a pericardial portaland positioning the distal end of the pericardial portal at the surfaceof the atrium.
 19. The method of claim 17, wherein the atrium is theleft atrium.
 20. The method of claim 17, further comprising using animaging device positioned at the distal end of the atrial portal toprovides an image of body structures present near the distal end of theatrial portal.
 21. The method of claim 17, further comprising providingsutures in the surface of the atrium that surround the entry locationfor the atrial portal and tightening the sutures around the atrialportal upon insertion of the atrial portal in the atrium to secure theatrial portal in the atrium.
 22. The method of claim 17, wherein thestep of inserting the atrial portal into the atrium comprises using aneedle contained within the atrial portal to puncture the atrium wall.23. The method of claim 17, wherein the step of inserting the atrialportal into the atrium comprises inserting a guide wire through theneedle, and withdrawing the needle such that the guide wire is insertedinto the atrium at the entry location for the atrial portal, and thenthreading the atrial portal over the guide wire and into the atrium. 24.The method of claim 17, wherein the step of inserting the atrial portalinto the atrium comprises inserting a dilating introducer positioned atthe distal end of the atrial portal into the entry location andadvancing the introducer distally into the atrium wall to enlarge theopening at the entry location.
 25. The method of claim 17, furthercomprising using a flexible cap positioned on the distal end of theatrial portal to secure the distal end of the atrial portal in theatrial wall.
 26. The method of claim 17, wherein at least a portion ofthe cap can be expanded laterally away from the central longitudinalaxis of the atrial portal.
 27. The method of claim 17, furthercomprising inserting a tool in the atrium using the atrial portal. 28.The method of claim 27, wherein the tool comprises at least one of anablation element, an electrode, a stent, a valve, an expandable, adebris capture device or a barbed needle.
 29. The method of claim 27,wherein the cardioscopic access is via an incision in the diaphragm andvia the pericardial space
 30. A system for accessing an atrium of aheart in a subject so as to perform a surgical procedure upon theatrium, the system comprising an atrial portal having a configurationsuch that the distal end of the atrial portal can provide cardioscopicaccess the atrium while the proximal end of the atrial portal can extendto outside of the subject.
 31. The system of claim 30, furthercomprising a pericardial portal into which the atrial portal isinserted, the pericardial portal having a configuration such that thedistal end of the atrial portal can access the atrium while the proximalend of the atrial portal can extend to outside of the subject.
 32. Thesystem of claim 30, further comprising at least one tool for performingprocedures on the atrium or a region of the heart accessible via theatrium.
 33. The system of claim 32, wherein the tool comprises at leastone of an ablation element, an electrode, a stent, a valve, anexpandable member, a debris capture device, or a barbed needle.